Healthcare Provider Details

I. General information

NPI: 1396324182
Provider Name (Legal Business Name): SARA ELIZABETH LANE SCOTT SAENGKEO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 GLEN COVE MARINA RD E STE 102
VALLEJO CA
94591-7237
US

IV. Provider business mailing address

3029 BROWNS VALLEY RD APT H
NAPA CA
94558-5463
US

V. Phone/Fax

Practice location:
  • Phone: 707-553-1784
  • Fax:
Mailing address:
  • Phone: 707-666-1059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-156407
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: