MEDICARE: FOTINI VAVELIDIS MS,CGC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	170300000X	Genetic Counselor (M.S.)	0139000044	VA
2	170300000X	Genetic Counselor (M.S.)

General Provider Information

NPI Number	:	1184749160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FOTINI VAVELIDIS MS,CGC

Provider Business Mailing Address
First Line	:	201 INDUSTRIAL RD STE 410
Second Line	:
City	:	SAN CARLOS
State	:	CA
Zip	:	94070-2396
Country	:	US
Telephone Number	:	650-249-9090
Fax Number	:	650-412-2305

Provider Business Practice Location Address
First Line	:	201 INDUSTRIAL RD STE 410
Second Line	:
City	:	SAN CARLOS
State	:	CA
Zip	:	94070-2396
Country	:	US
Telephone Number	:	650-249-9090
Fax Number	:	650-412-2305

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	08/30/2024

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