Provider Demographics
NPI:1720606247
Name:SAUCEDO MACIAS, FABIOLA
Entity Type:Individual
Prefix:
First Name:FABIOLA
Middle Name:
Last Name:SAUCEDO MACIAS
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 1:712 N SEQUOIA LN
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-2622
Mailing Address - Country:US
Mailing Address - Phone:626-673-9035
Mailing Address - Fax:
Practice Address - Street 1:1160 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-5000
Practice Address - Country:US
Practice Address - Phone:424-306-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAASW103773101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program