Healthcare Provider Details

I. General information

NPI: 1710585484
Provider Name (Legal Business Name): LISETTE MACIEL HERNANDEZ APCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2020
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3508 DALE RD STE B
MODESTO CA
95356-0794
US

IV. Provider business mailing address

2748 SANTIAGO DR
MODESTO CA
95354-3236
US

V. Phone/Fax

Practice location:
  • Phone: 209-721-6630
  • Fax:
Mailing address:
  • Phone: 559-517-4257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number20017
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: