Provider Demographics
NPI:1457708596
Name:LANCTOT, MAGGIE ALINE (MS, ATC)
Entity Type:Individual
Prefix:
First Name:MAGGIE
Middle Name:ALINE
Last Name:LANCTOT
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 E 1ST ST
Mailing Address - Street 2:4B
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-6109
Mailing Address - Country:US
Mailing Address - Phone:714-486-9673
Mailing Address - Fax:
Practice Address - Street 1:1906 E 1ST ST
Practice Address - Street 2:4B
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-6109
Practice Address - Country:US
Practice Address - Phone:714-486-9673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2000004100174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2000004100OtherBOARD OF CERTIFICATION