Healthcare Provider Details

I. General information

NPI: 1740847284
Provider Name (Legal Business Name): MISS GLORIA ANN FEDERICO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2019
Last Update Date: 05/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39210 STATE ST. SUITE 220 FREMONT, CA 94538
FREMONT CA
94538
US

IV. Provider business mailing address

3216 EVERDALE DR
SAN JOSE CA
95148-3405
US

V. Phone/Fax

Practice location:
  • Phone: 510-894-4135
  • Fax:
Mailing address:
  • Phone: 408-771-2505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number46-1305562
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: