Healthcare Provider Details

I. General information

NPI: 1225368129
Provider Name (Legal Business Name): MAGGIE JANET SEBASTIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MAGGIE JANET FUNES

II. Dates (important events)

Enumeration Date: 12/28/2009
Last Update Date: 08/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 INDUSTRY WAY
LYNWOOD CA
90262
US

IV. Provider business mailing address

2620 INDUSTRY WAY
LYNWOOD CA
90262-4024
US

V. Phone/Fax

Practice location:
  • Phone: 310-667-4070
  • Fax:
Mailing address:
  • Phone: 310-661-4070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number83971
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: