Provider Demographics
NPI:1326520107
Name:MINNOCCI, MACY KAITLYN
Entity type:Individual
Prefix:
First Name:MACY
Middle Name:KAITLYN
Last Name:MINNOCCI
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:MACY
Other - Middle Name:KAITLYN
Other - Last Name:GOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11545 WINDCREST LN APT 193
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-4241
Mailing Address - Country:US
Mailing Address - Phone:408-594-8686
Mailing Address - Fax:
Practice Address - Street 1:734 10TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-6502
Practice Address - Country:US
Practice Address - Phone:619-239-4663
Practice Address - Fax:619-239-3045
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX40624103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program