=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710585484
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISETTE MACIEL HERNANDEZ APCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2020
-----------------------------------------------------
Last Update Date | 09/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3508 DALE RD STE B
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95356-0794
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-721-6630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2748 SANTIAGO DR
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95354-3236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-517-4257
-----------------------------------------------------
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 | 20017
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------