Provider Demographics
NPI:1225368129
Name:SEBASTIAN, MAGGIE JANET
Entity Type:Individual
Prefix:
First Name:MAGGIE
Middle Name:JANET
Last Name:SEBASTIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MAGGIE
Other - Middle Name:JANET
Other - Last Name:FUNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2620 INDUSTRY WAY
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-4024
Mailing Address - Country:US
Mailing Address - Phone:310-661-4070
Mailing Address - Fax:
Practice Address - Street 1:2620 INDUSTRY WAY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262
Practice Address - Country:US
Practice Address - Phone:310-667-4070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-28
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83971101YM0800X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health