Basic Information
| Provider Information | |||||||||
| NPI: | 1477843902 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACIAS | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MFTI | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MACIAS | ||||||||
| OtherFirstName: | MARIO | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | JR. | ||||||||
| OtherCredential: | MFTI | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6401 SHELLMOUND ST APT 6216 | ||||||||
| Address2: | |||||||||
| City: | EMERYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946081065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594170380 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 511 ESTUDILLO AVE | ||||||||
| Address2: | |||||||||
| City: | SAN LEANDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945774611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107467480 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2011 | ||||||||
| LastUpdateDate: | 02/19/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | IMF73931 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.