Provider Demographics
NPI:1528212461
Name:ELICEGUI, ADRIAN GABRIEL
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:GABRIEL
Last Name:ELICEGUI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 N GRAND AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-1551
Mailing Address - Country:US
Mailing Address - Phone:626-967-1667
Mailing Address - Fax:
Practice Address - Street 1:1126 N GRAND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-1551
Practice Address - Country:US
Practice Address - Phone:626-967-1667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 225400000X
CA390200000X
CALCSW879141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program