Healthcare Provider Details

I. General information

NPI: 1225529225
Provider Name (Legal Business Name): TONYA SHANTA MCDONALD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2018
Last Update Date: 05/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 CUMMINS DR
MODESTO CA
95358-6400
US

IV. Provider business mailing address

1620 CUMMINS DR
MODESTO CA
95358-6400
US

V. Phone/Fax

Practice location:
  • Phone: 209-622-1420
  • Fax: 209-491-0627
Mailing address:
  • Phone: 209-622-1420
  • Fax: 209-491-0627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: