MEDICARE: HOPRAYA SHALON STIDOM

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	135152	CA
2	101YM0800X	Mental Health Counselor	12757	CA
3	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1376005041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOPRAYA SHALON STIDOM

Provider Business Mailing Address
First Line	:	9711 HOLLAND ST STE 1
Second Line	:
City	:	BAKERSFIELD
State	:	CA
Zip	:	93312-2773
Country	:	US
Telephone Number	:	805-561-8914
Fax Number	:

Provider Business Practice Location Address
First Line	:	9711 HOLLAND ST STE 1
Second Line	:
City	:	BAKERSFIELD
State	:	CA
Zip	:	93312-2773
Country	:	US
Telephone Number	:	805-561-8914
Fax Number	:

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

Provider Enumeration Date	:	04/02/2019
Last Update Date	:	04/12/2026

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