Provider Demographics
NPI:1275883084
Name:PELLETIER-JUAREZ, ANGIE SUSANA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ANGIE
Middle Name:SUSANA
Last Name:PELLETIER-JUAREZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:ANGIE
Other - Middle Name:SUSANA
Other - Last Name:JUAREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17401 VINTAGE ST
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-1538
Mailing Address - Country:US
Mailing Address - Phone:323-559-2836
Mailing Address - Fax:
Practice Address - Street 1:17401 VINTAGE ST
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-1538
Practice Address - Country:US
Practice Address - Phone:323-559-2836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
CA34099103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist