Provider Demographics
NPI:1780426833
Name:SANJUAN, MAYRA LIZETH (LAC, DTCM)
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:LIZETH
Last Name:SANJUAN
Suffix:
Gender:F
Credentials:LAC, DTCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 7TH AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-4669
Mailing Address - Country:US
Mailing Address - Phone:831-476-9424
Mailing Address - Fax:
Practice Address - Street 1:200 7TH AVE STE 115
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-4669
Practice Address - Country:US
Practice Address - Phone:831-476-9424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20085171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist