Provider Demographics
NPI:1659713238
Name:MAESTAS, MARCELLA
Entity Type:Individual
Prefix:
First Name:MARCELLA
Middle Name:
Last Name:MAESTAS
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:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-0520
Mailing Address - Country:US
Mailing Address - Phone:505-753-2203
Mailing Address - Fax:505-747-1881
Practice Address - Street 1:612 N PASEO DE ONATE
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2963
Practice Address - Country:US
Practice Address - Phone:505-753-2203
Practice Address - Fax:505-747-1881
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME7436Medicaid