Healthcare Provider Details

I. General information

NPI: 1346502218
Provider Name (Legal Business Name): MAIJA THACKERSON L.P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4151 E FOUNTAIN ST
LONG BEACH CA
90804-3023
US

IV. Provider business mailing address

4151 E FOUNTAIN ST
LONG BEACH CA
90804-3023
US

V. Phone/Fax

Practice location:
  • Phone: 562-719-9250
  • Fax: 562-719-9261
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT 16398
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: