Provider Demographics
NPI:1275221673
Name:HEREDIA, ANGELICA
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:
Last Name:HEREDIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGEL
Other - Middle Name:
Other - Last Name:HEREDIA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1020 CENTRAL AVE SW APT 205
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-4552
Mailing Address - Country:US
Mailing Address - Phone:713-775-2326
Mailing Address - Fax:
Practice Address - Street 1:1020 CENTRAL AVE SW APT 205
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-4552
Practice Address - Country:US
Practice Address - Phone:713-775-2326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician