Provider Demographics
NPI:1114236551
Name:LA LUZ, ANGELICA MARIA (LCSW)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:MARIA
Last Name:LA LUZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3643 WALTON WAY EXTENSION
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-4507
Mailing Address - Country:US
Mailing Address - Phone:706-364-1404
Mailing Address - Fax:706-364-1419
Practice Address - Street 1:3643 WALTON WAY EXT
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-4507
Practice Address - Country:US
Practice Address - Phone:706-364-1404
Practice Address - Fax:706-364-1419
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0042111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical