Provider Demographics
NPI:1477255735
Name:COMIA, MARY ERYZA ANGELINE P
Entity Type:Individual
Prefix:
First Name:MARY ERYZA ANGELINE
Middle Name:P
Last Name:COMIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:COMIA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:2167 SHAW AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-8935
Mailing Address - Country:US
Mailing Address - Phone:949-354-4442
Mailing Address - Fax:
Practice Address - Street 1:2660 VICTOR AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-1432
Practice Address - Country:US
Practice Address - Phone:949-354-4442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13614101YP2500X
CA138709106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA138709Medicaid