Provider Demographics
NPI:1164970794
Name:ACOSTA, MARIBEL RODRIGUEZ
Entity Type:Individual
Prefix:
First Name:MARIBEL
Middle Name:RODRIGUEZ
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIBEL
Other - Middle Name:
Other - Last Name:RODRIGUEZ-ESPARZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3886 E FARRIN AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-5116
Mailing Address - Country:US
Mailing Address - Phone:559-304-5337
Mailing Address - Fax:
Practice Address - Street 1:1630 E SHAW AVE STE 150
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-8109
Practice Address - Country:US
Practice Address - Phone:559-248-8550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB9835622171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator