Provider Demographics
NPI:1821697178
Name:WRIGHT, MICQWAUN ANGELO
Entity Type:Individual
Prefix:
First Name:MICQWAUN
Middle Name:ANGELO
Last Name:WRIGHT
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 1:8510 CENTURY BLVD UNIT D
Mailing Address - Street 2:
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723
Mailing Address - Country:US
Mailing Address - Phone:562-417-4350
Mailing Address - Fax:
Practice Address - Street 1:108 W VICTORIA ST
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-3523
Practice Address - Country:US
Practice Address - Phone:310-747-3165
Practice Address - Fax:562-282-0133
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1162121041C0700X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
0117OtherKAISER