Provider Demographics
NPI:1821548462
Name:MACEDO, RACHEL (RADT1)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:MACEDO
Suffix:
Gender:F
Credentials:RADT1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 MCHENRY VILLAGE WAY STE 16
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4341
Mailing Address - Country:US
Mailing Address - Phone:209-527-3270
Mailing Address - Fax:209-527-3226
Practice Address - Street 1:3125 MCHENRY AVE
Practice Address - Street 2:STE D
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-1451
Practice Address - Country:US
Practice Address - Phone:209-523-6910
Practice Address - Fax:209-523-6912
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-06
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA500010BN324500000X
CAR1234950716101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility