Healthcare Provider Details

I. General information

NPI: 1629947254
Provider Name (Legal Business Name): MAYCIE CEREGHINO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E JANSS RD
THOUSAND OAKS CA
91362-2198
US

IV. Provider business mailing address

3075 APACHE CIR
THOUSAND OAKS CA
91360-1024
US

V. Phone/Fax

Practice location:
  • Phone: 805-497-9511
  • Fax:
Mailing address:
  • Phone: 805-907-8658
  • Fax:

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 StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: