1700207206 NPI number — MRS. ANGELICA PELAYO-HICKLIN

Table of content: MRS. ANGELICA PELAYO-HICKLIN (NPI 1700207206)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700207206 NPI number — MRS. ANGELICA PELAYO-HICKLIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PELAYO-HICKLIN
Provider First Name:
ANGELICA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700207206
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16350 FILBERT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYLMAR
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91342-1002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-364-2152
Provider Business Mailing Address Fax Number:
818-362-3446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16350 FILBERT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYLMAR
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91342-1002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-364-2152
Provider Business Practice Location Address Fax Number:
818-362-3446
Provider Enumeration Date:
12/31/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  LCSW 75353 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 75353 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7420 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7068 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6758 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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