=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609511575
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SENY MADRIZ FAJARDO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2022
-----------------------------------------------------
Last Update Date | 05/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 908 SIERRA DR
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95351-3254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-492-9785
-----------------------------------------------------
Fax | 209-492-9174
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16817 MYERS LN
-----------------------------------------------------
City | DELHI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95315-9259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-648-5515
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------