Provider Demographics
NPI:1528605094
Name:SAN MIGUEL, PAOLA
Entity Type:Individual
Prefix:
First Name:PAOLA
Middle Name:
Last Name:SAN MIGUEL
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 1:1501 MIMOSA ST APT C
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-8054
Mailing Address - Country:US
Mailing Address - Phone:831-902-8594
Mailing Address - Fax:
Practice Address - Street 1:9360 N NAME UNO STE 130
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-3535
Practice Address - Country:US
Practice Address - Phone:408-843-9350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY8293447106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician