MEDICARE: MS. ANEITA SHARPLES RADOV MA, LMFT, CEAP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFC 19712	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0001007006	OTHER	CA	MANAGED HEALTH NET VENDOR
2	54220ZZZ95485Z	OTHER	CA	BLUE SHIELD OF CA

General Provider Information

NPI Number	:	1235163411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANEITA SHARPLES RADOV MA, LMFT, CEAP

Provider Business Mailing Address
First Line	:	3121 PARK AVE
Second Line	:	SUITE I
City	:	SOQUEL
State	:	CA
Zip	:	95073-2920
Country	:	US
Telephone Number	:	831-476-1552
Fax Number	:	831-476-4750

Provider Business Practice Location Address
First Line	:	3121 PARK AVE
Second Line	:	SUITE I
City	:	SOQUEL
State	:	CA
Zip	:	95073-2920
Country	:	US
Telephone Number	:	831-476-1552
Fax Number	:	831-476-4750

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	07/08/2007

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