Healthcare Provider Details

I. General information

NPI: 1053504472
Provider Name (Legal Business Name): MRS. PATRICE E AGREDANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2007
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 I ST
DAVIS CA
95616-4213
US

IV. Provider business mailing address

1451 ROCKY RIDGE DR APT 1109
ROSEVILLE CA
95661-3007
US

V. Phone/Fax

Practice location:
  • Phone: 530-601-5959
  • Fax: 916-287-4679
Mailing address:
  • Phone: 916-320-2503
  • Fax: 916-283-8259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number102263
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: