Provider Demographics
NPI:1679262042
Name:AZEVEDO, CHERSTEN
Entity type:Individual
Prefix:
First Name:CHERSTEN
Middle Name:
Last Name:AZEVEDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 W HENDERSON AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-1777
Mailing Address - Country:US
Mailing Address - Phone:595-784-0312
Mailing Address - Fax:559-784-5827
Practice Address - Street 1:177 W HENDERSON AVE STE 1
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-1777
Practice Address - Country:US
Practice Address - Phone:559-687-0929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-02
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA120723104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker