Provider Demographics
NPI:1659142040
Name:MACEDO, SHANDALEE KIMBERLEE
Entity Type:Individual
Prefix:
First Name:SHANDALEE
Middle Name:KIMBERLEE
Last Name:MACEDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 OHIO AVE APT 304
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-2450
Mailing Address - Country:US
Mailing Address - Phone:951-807-8204
Mailing Address - Fax:
Practice Address - Street 1:1365 OHIO AVE APT 304
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-2450
Practice Address - Country:US
Practice Address - Phone:951-807-8204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 103TF0000X, 103TS0200X
NY29049122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC236Medicaid
5874OtherHEALTH PARTNERS
568946544OtherBCBS