Provider Demographics
NPI:1053880591
Name:SEVILLA, JOHN JOSEPH BENEDICT
Entity type:Individual
Prefix:
First Name:JOHN JOSEPH BENEDICT
Middle Name:
Last Name:SEVILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2267
Mailing Address - Street 2:
Mailing Address - City:SEPULVEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91393-2267
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 E HOLT AVE STE B
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5407
Practice Address - Country:US
Practice Address - Phone:909-620-2521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109377106H00000X
CA141170106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist