Healthcare Provider Details

I. General information

NPI: 1720606247
Provider Name (Legal Business Name): FABIOLA SAUCEDO MACIAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2020
Last Update Date: 01/24/2022
Certification Date: 01/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 S GRAND AVE
GLENDORA CA
91740-5000
US

IV. Provider business mailing address

712 N SEQUOIA LN
AZUSA CA
91702-2622
US

V. Phone/Fax

Practice location:
  • Phone: 424-306-4000
  • Fax:
Mailing address:
  • Phone: 626-673-9035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW103773
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: