=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639961634
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHYLICIA NICOLE MEDEIROS SCHOOL PSYCHOLOGY
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2025
-----------------------------------------------------
Last Update Date | 05/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1757 FLAXEN CT # 59
-----------------------------------------------------
City | MANTECA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95337-8152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-535-2415
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1757 FLAXEN CT
-----------------------------------------------------
City | MANTECA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95337-8152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-535-2415
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 230188558
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------