Basic Information
| Provider Information | |||||||||
| NPI: | 1588796569 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ISLAS | ||||||||
| FirstName: | MARITZA | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PAEZ | ||||||||
| OtherFirstName: | MARITZA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 160 S 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | LA PUENTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917463211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269740770 | ||||||||
| FaxNumber: | 6269740774 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 S 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | LA PUENTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917463211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269740770 | ||||||||
| FaxNumber: | 6269740774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 12/22/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 50898 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.