Provider Demographics
NPI:1003200676
Name:MACIAS, JOSETTE M
Entity type:Individual
Prefix:
First Name:JOSETTE
Middle Name:M
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 1:301 N ST LOUIS ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-2807
Mailing Address - Country:US
Mailing Address - Phone:323-836-4483
Mailing Address - Fax:
Practice Address - Street 1:17727 E CYPRESS ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91722-2634
Practice Address - Country:US
Practice Address - Phone:626-967-2677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-23
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA120141171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA120141OtherSUBSTANCE ABUSE