Provider Demographics
NPI:1245941624
Name:MARISCAL, GUADALUPE MACIAS (PEER SUPPORT SPECIAL)
Entity type:Individual
Prefix:
First Name:GUADALUPE
Middle Name:MACIAS
Last Name:MARISCAL
Suffix:
Gender:F
Credentials:PEER SUPPORT SPECIAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44199 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-3096
Mailing Address - Country:US
Mailing Address - Phone:760-863-8424
Mailing Address - Fax:
Practice Address - Street 1:44199 MONROE ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3096
Practice Address - Country:US
Practice Address - Phone:760-863-8424
Practice Address - Fax:760-770-2240
Is Sole Proprietor?:No
Enumeration Date:2022-12-07
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)