Provider Demographics
NPI:1639670003
Name:MACARAEG, ANGELICA MARIE (LMT)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:MARIE
Last Name:MACARAEG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 TERRYVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-4078
Mailing Address - Country:US
Mailing Address - Phone:860-589-1491
Mailing Address - Fax:860-583-3581
Practice Address - Street 1:665 TERRYVILLE AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-4078
Practice Address - Country:US
Practice Address - Phone:860-589-1491
Practice Address - Fax:860-583-3581
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005978225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist