Provider Demographics
NPI:1376150904
Name:DE LUNA, MAXINE MARTHA
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:MARTHA
Last Name:DE LUNA
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 1:41 E FOOTHILL BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-2361
Mailing Address - Country:US
Mailing Address - Phone:626-701-4249
Mailing Address - Fax:626-737-6034
Practice Address - Street 1:1333 S MAYFLOWER AVE STE 360
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-5280
Practice Address - Country:US
Practice Address - Phone:626-701-4249
Practice Address - Fax:626-737-6034
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA118660106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA118660OtherBBS