Provider Demographics
NPI:1932600947
Name:MACIAS, SUSANA (MA BCBA)
Entity Type:Individual
Prefix:MRS
First Name:SUSANA
Middle Name:
Last Name:MACIAS
Suffix:
Gender:F
Credentials:MA BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 ROSEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-2038
Mailing Address - Country:US
Mailing Address - Phone:209-872-4527
Mailing Address - Fax:
Practice Address - Street 1:2303 WHISTLER WAY
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-4157
Practice Address - Country:US
Practice Address - Phone:209-953-8106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-24
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-21-55325103K00000X
CARBT-17-45747106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty