Healthcare Provider Details

I. General information

NPI: 1679300362
Provider Name (Legal Business Name): MAEGAN PUMMELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13525 CIELO AZUL WAY
DESERT HOT SPRINGS CA
92240-6235
US

IV. Provider business mailing address

13525 CIELO AZUL WAY
DESERT HOT SPRINGS CA
92240-6235
US

V. Phone/Fax

Practice location:
  • Phone: 951-796-0386
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: