=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801088737
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RENEE MARIE AZEVEDO LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2007
-----------------------------------------------------
Last Update Date | 08/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3732 MT DIABLO BLVD SUITE 395
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94549-3632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-335-8105
-----------------------------------------------------
Fax | 800-450-5024
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 162953
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95816-2953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-335-8105
-----------------------------------------------------
Fax | 800-450-5024
-----------------------------------------------------
=====================================================
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 | 51072
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------