Provider Demographics
NPI:1629738588
Name:JUANSO, ANGEL N
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:N
Last Name:JUANSO
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 1:18726 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3813
Mailing Address - Country:US
Mailing Address - Phone:310-856-0800
Mailing Address - Fax:
Practice Address - Street 1:90 CANAL ST FL 4
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2018
Practice Address - Country:US
Practice Address - Phone:888-922-2843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician