Basic Information
Provider Information
NPI: 1003299025
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MAGAZZU
FirstName: MICAELA
MiddleName:  
NamePrefix: MS.
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: MAGAZZU
OtherFirstName: MICAELA
OtherMiddleName:  
OtherNamePrefix: MS.
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 5
Mailing Information
Address1: 4655 OHIO ST UNIT 27
Address2:  
City: SAN DIEGO
State: CA
PostalCode: 921163284
CountryCode: US
TelephoneNumber: 6195404303
FaxNumber:  
Practice Location
Address1: 1400 N JOHNSON AVE
Address2: #101
City: EL CAJON
State: CA
PostalCode: 920201650
CountryCode: US
TelephoneNumber: 6194420277
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/08/2015
LastUpdateDate: 12/05/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106H00000X95925CAY Behavioral Health & Social Service ProvidersMarriage & Family Therapist 
390200000X CAN Student, Health CareStudent in an Organized Health Care Education/Training Program 

No ID Information.


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