Provider Demographics
NPI:1497352033
Name:JUAREZ, MARIA CRISSELDA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:CRISSELDA
Last Name:JUAREZ
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 1:11859 W CRESTED BUTTE CT
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-8164
Mailing Address - Country:US
Mailing Address - Phone:208-957-3294
Mailing Address - Fax:
Practice Address - Street 1:11859 W CRESTED BUTTE CT
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-8164
Practice Address - Country:US
Practice Address - Phone:208-957-3294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID106S00000XMedicaid