Provider Demographics
NPI:1245782069
Name:MACIAS, NIDIA CLARK
Entity Type:Individual
Prefix:
First Name:NIDIA
Middle Name:CLARK
Last Name:MACIAS
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 1:500 CITY PKWY W STE 200
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-2941
Mailing Address - Country:US
Mailing Address - Phone:714-480-6600
Mailing Address - Fax:
Practice Address - Street 1:500 CITY PKWY W STE 200
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-2941
Practice Address - Country:US
Practice Address - Phone:714-480-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA135675106H00000X
CAAMFT95703106H00000X
CAAMFT135675106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist