Provider Demographics
NPI:1043043631
Name:CABELLO, OSVALDO M
Entity type:Individual
Prefix:
First Name:OSVALDO
Middle Name:M
Last Name:CABELLO
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 1:521 E HARRISON AVE # A
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1915
Mailing Address - Country:US
Mailing Address - Phone:909-455-2675
Mailing Address - Fax:
Practice Address - Street 1:1212 N SAN DIMAS CANYON RD
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1223
Practice Address - Country:US
Practice Address - Phone:626-345-6455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician