Provider Demographics
NPI:1730221458
Name:FULLINWIDER, YOLANDA VELAZQUEZ (MA)
Entity type:Individual
Prefix:
First Name:YOLANDA
Middle Name:VELAZQUEZ
Last Name:FULLINWIDER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2975 S BUENA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-7540
Mailing Address - Country:US
Mailing Address - Phone:951-898-1555
Mailing Address - Fax:
Practice Address - Street 1:1688 N. PERRIS BLVD. STE. L7-11
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571
Practice Address - Country:US
Practice Address - Phone:951-443-2204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC40392106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist