Provider Demographics
NPI:1447929161
Name:REA, ANGELICA RUBY
Entity type:Individual
Prefix:MISS
First Name:ANGELICA
Middle Name:RUBY
Last Name:REA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 E SAN JOAQUIN ST
Mailing Address - Street 2:
Mailing Address - City:AVENAL
Mailing Address - State:CA
Mailing Address - Zip Code:93204-1346
Mailing Address - Country:US
Mailing Address - Phone:559-826-9249
Mailing Address - Fax:
Practice Address - Street 1:304 E SAN JOAQUIN ST
Practice Address - Street 2:
Practice Address - City:AVENAL
Practice Address - State:CA
Practice Address - Zip Code:93204-1346
Practice Address - Country:US
Practice Address - Phone:559-826-9249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst