Provider Demographics
NPI:1801914577
Name:MAEZ, ANGELITA (PHD)
Entity type:Individual
Prefix:
First Name:ANGELITA
Middle Name:
Last Name:MAEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:ANGIE
Other - Middle Name:
Other - Last Name:MAEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:3960 VIA LUCERO APT 12
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93110-1648
Mailing Address - Country:US
Mailing Address - Phone:805-569-3139
Mailing Address - Fax:805-988-2240
Practice Address - Street 1:3960 VIA LUCERO APT 12
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93110-1648
Practice Address - Country:US
Practice Address - Phone:805-569-3139
Practice Address - Fax:805-988-2240
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12363302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization