Healthcare Provider Details

I. General information

NPI: 1366584336
Provider Name (Legal Business Name): GUADALUPE VACA M.S. DEGREE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 03/03/2024
Certification Date: 03/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5588 N PALM AVE
FRESNO CA
93704-1913
US

IV. Provider business mailing address

5588 N PALM AVE
FRESNO CA
93704-1913
US

V. Phone/Fax

Practice location:
  • Phone: 559-804-4599
  • Fax: 559-775-2556
Mailing address:
  • Phone: 559-804-4599
  • Fax: 559-775-2556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number42966
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number42966
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: