Provider Demographics
NPI:1063929693
Name:IRAHETA, ANGIE SOPHIA
Entity type:Individual
Prefix:MISS
First Name:ANGIE
Middle Name:SOPHIA
Last Name:IRAHETA
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 1:13130 BURBANK BLVD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-6000
Mailing Address - Country:US
Mailing Address - Phone:818-781-0360
Mailing Address - Fax:
Practice Address - Street 1:13130 BURBANK BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91401
Practice Address - Country:US
Practice Address - Phone:818-781-0360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-04
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CAASW84476101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician