Provider Demographics
NPI:1376936476
Name:MACIAS, LIBERTY (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:LIBERTY
Middle Name:
Last Name:MACIAS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1303
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-1303
Mailing Address - Country:US
Mailing Address - Phone:909-894-4846
Mailing Address - Fax:888-505-0620
Practice Address - Street 1:10459 MOUNTAIN VIEW AVE STE E
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2033
Practice Address - Country:US
Practice Address - Phone:909-792-6262
Practice Address - Fax:888-505-0620
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002264363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health