Basic Information
Provider Information | |||||||||
NPI: | 1962494328 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | O'TUEL | ||||||||
FirstName: | MARIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSYD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | O'TUEL | ||||||||
OtherFirstName: | MARIA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PSYD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 21545 CENTRE POINTE PKWY | ||||||||
Address2: |   | ||||||||
City: | SANTA CLARITA | ||||||||
State: | CA | ||||||||
PostalCode: | 913502947 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6612599439 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 21545 CENTRE POINTE PKWY | ||||||||
Address2: |   | ||||||||
City: | SANTA CLARITA | ||||||||
State: | CA | ||||||||
PostalCode: | 913502947 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6612599439 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/22/2005 | ||||||||
LastUpdateDate: | 05/21/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 2694 | NC | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 6000728 | 05 | NC |   | MEDICAID | 046R4 | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 60-00175 | 01 |   | EVERCARE | OTHER |