Provider Demographics
NPI:1013040245
Name:MICO, MARIA REGINA LARDIZABAL
Entity Type:Individual
Prefix:MRS
First Name:MARIA REGINA
Middle Name:LARDIZABAL
Last Name:MICO
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 1:3824 LOUISBURG AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-1324
Mailing Address - Country:US
Mailing Address - Phone:209-525-7432
Mailing Address - Fax:
Practice Address - Street 1:707 14TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-2506
Practice Address - Country:US
Practice Address - Phone:209-525-6041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator