MEDICARE: SAIRA PRUDENCIO LMFT

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 49108	CA

General Provider Information

NPI Number	:	1710021316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAIRA PRUDENCIO LMFT

Provider Business Mailing Address
First Line	:	31946 MISSION TRL STE B
Second Line	:
City	:	LAKE ELSINORE
State	:	CA
Zip	:	92530-4539
Country	:	US
Telephone Number	:	951-245-7748
Fax Number	:	951-674-6431

Provider Business Practice Location Address
First Line	:	31946 MISSION TRL STE B
Second Line	:
City	:	LAKE ELSINORE
State	:	CA
Zip	:	92530-4539
Country	:	US
Telephone Number	:	951-245-7748
Fax Number	:	951-674-6431

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

Provider Enumeration Date	:	02/16/2007
Last Update Date	:	04/08/2013

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