Provider Demographics
NPI:1295914778
Name:MARES, MIGUEL ANGEL (ASW)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANGEL
Last Name:MARES
Suffix:
Gender:M
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 MERRITT AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-5169
Mailing Address - Country:US
Mailing Address - Phone:760-695-7498
Mailing Address - Fax:
Practice Address - Street 1:795 WILLOW RD
Practice Address - Street 2:BUILDING 324, OFFICE # B147
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-2539
Practice Address - Country:US
Practice Address - Phone:650-493-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA22083OtherASW