Basic Information
| Provider Information | |||||||||
| NPI: | 1629302336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACIEL | ||||||||
| FirstName: | CHRISTIAN | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MACIEL | ||||||||
| OtherFirstName: | CHRISTIAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMFT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 91275 66TH AVE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | MECCA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922546515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603961249 | ||||||||
| FaxNumber: | 7603961253 | ||||||||
| Practice Location | |||||||||
| Address1: | 91275 66TH AVE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | MECCA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922546515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603961249 | ||||||||
| FaxNumber: | 7603961253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2009 | ||||||||
| LastUpdateDate: | 07/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 35001725A | IN | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 49560 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.