Provider Demographics
NPI:1740458405
Name:MACIAS, BERNICE ANN (MA, LPC, LISAC)
Entity type:Individual
Prefix:
First Name:BERNICE
Middle Name:ANN
Last Name:MACIAS
Suffix:
Gender:F
Credentials:MA, LPC, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 546
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85380-0546
Mailing Address - Country:US
Mailing Address - Phone:623-221-3466
Mailing Address - Fax:
Practice Address - Street 1:18001 N 79TH AVE
Practice Address - Street 2:SUITE B45
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8388
Practice Address - Country:US
Practice Address - Phone:623-221-3466
Practice Address - Fax:623-334-6724
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-15
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10993101YA0400X
AZLPC-12397101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)