Provider Demographics
NPI:1679390686
Name:MACIAS, VANESSA (LMT, LE, HHP)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:MACIAS
Suffix:
Gender:F
Credentials:LMT, LE, HHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 VIA PICO PLZ
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-3998
Mailing Address - Country:US
Mailing Address - Phone:949-870-9171
Mailing Address - Fax:
Practice Address - Street 1:99 VIA PICO PLZ
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-3998
Practice Address - Country:US
Practice Address - Phone:949-870-9171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-21
Last Update Date:2024-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76609225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist