Basic Information
| Provider Information | |||||||||
| NPI: | 1164628723 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUAREZ | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JUAREZ | ||||||||
| OtherFirstName: | REYNA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12 W BEACH ST | ||||||||
| Address2: | |||||||||
| City: | WATSONVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950764504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317638952 | ||||||||
| FaxNumber: | 8317638591 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 W BEACH ST | ||||||||
| Address2: | |||||||||
| City: | WATSONVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950764504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317638952 | ||||||||
| FaxNumber: | 8317638591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | C6689836 | 01 | CA | LICENSE | OTHER |