Provider Demographics
NPI:1972010775
Name:MACIAS, AMANDA JESSICA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JESSICA
Last Name:MACIAS
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 1:1401 PALM AVE APT B
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-3368
Mailing Address - Country:US
Mailing Address - Phone:626-297-5679
Mailing Address - Fax:
Practice Address - Street 1:529 E LIVE OAK AVE STE E
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-5600
Practice Address - Country:US
Practice Address - Phone:626-538-2751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44432355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant