=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659142040
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANDALEE KIMBERLEE MACEDO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2024
-----------------------------------------------------
Last Update Date | 01/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1365 OHIO AVE APT 304
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90804-2450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-807-8204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1365 OHIO AVE APT 304
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90804-2450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-807-8204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TF0000X
-----------------------------------------------------
Taxonomy Name | Family Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 29049
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------