=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023743424
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROLINE GRACE CHAVEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2022
-----------------------------------------------------
Last Update Date | 08/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 CIRBY HILLS DR
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95678-4360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-787-8860
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2130 STOCKTON BLVD # 300
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95817-1337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-520-2460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 167G00000X
-----------------------------------------------------
Taxonomy Name | Licensed Psychiatric Technician
-----------------------------------------------------
License Number | 42878
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------