Provider Demographics
NPI:1275878159
Name:DEJESUS, DAISY C
Entity type:Individual
Prefix:
First Name:DAISY
Middle Name:C
Last Name:DEJESUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DAISY
Other - Middle Name:CONDE
Other - Last Name:SANCHEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3533 LARIAT WAY
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:CA
Mailing Address - Zip Code:93510-1244
Mailing Address - Country:US
Mailing Address - Phone:818-388-0093
Mailing Address - Fax:
Practice Address - Street 1:190 SIERRA CT STE C4
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-7609
Practice Address - Country:US
Practice Address - Phone:661-463-0496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-04
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CALMFT109995106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL