Provider Demographics
NPI:1871059253
Name:COELHO, MARY ALICE (DACM, LAC)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ALICE
Last Name:COELHO
Suffix:
Gender:F
Credentials:DACM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1169 PACIFIC BEACH DR APT C
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5183
Mailing Address - Country:US
Mailing Address - Phone:559-380-5821
Mailing Address - Fax:
Practice Address - Street 1:1169 PACIFIC BEACH DR APT C
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-5183
Practice Address - Country:US
Practice Address - Phone:559-380-5821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC18269171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty