Healthcare Provider Details

I. General information

NPI: 1962105601
Provider Name (Legal Business Name): FABIOLA STEPHANY ORNELAS MARISCAL SUDCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 ARNOLD DR STE 225
MARTINEZ CA
94553-4189
US

IV. Provider business mailing address

1340 ARNOLD DR STE 225
MARTINEZ CA
94553-4189
US

V. Phone/Fax

Practice location:
  • Phone: 925-655-2408
  • Fax:
Mailing address:
  • Phone: 925-655-2408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number11405
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: