Healthcare Provider Details

I. General information

NPI: 1760924179
Provider Name (Legal Business Name): STACEY TERRIQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2016
Last Update Date: 11/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 E FOOTHILL BLVD STE 300
PASADENA CA
91107-7102
US

IV. Provider business mailing address

2500 E FOOTHILL BLVD STE 300
PASADENA CA
91107-7102
US

V. Phone/Fax

Practice location:
  • Phone: 626-993-3057
  • Fax: 626-993-3084
Mailing address:
  • Phone: 626-993-3057
  • Fax: 626-993-3084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: