=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174006076
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RITA YACOUB LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2018
-----------------------------------------------------
Last Update Date | 04/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 251 E HACKETT RD
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95358-9800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-558-2254
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18837 BROOKHURST ST STE 110 & STE 104
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708-7301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-416-6053
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 131099
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------