Basic Information
| Provider Information | |||||||||
| NPI: | 1700207206 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PELAYO-HICKLIN | ||||||||
| FirstName: | ANGELICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 16350 FILBERT ST | ||||||||
| Address2: | |||||||||
| City: | SYLMAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913421002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183642152 | ||||||||
| FaxNumber: | 8183623446 | ||||||||
| Practice Location | |||||||||
| Address1: | 16350 FILBERT ST | ||||||||
| Address2: | |||||||||
| City: | SYLMAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913421002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183642152 | ||||||||
| FaxNumber: | 8183623446 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2013 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LCSW 75353 | CA | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 75353 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 7420 | 05 | CA | MEDICAID | 7068 | 05 | CA | MEDICAID | 6758 | 05 | CA | MEDICAID |