Provider Demographics
NPI:1801088737
Name:AZEVEDO, RENEE MARIE (LMFT)
Entity type:Individual
Prefix:MISS
First Name:RENEE
Middle Name:MARIE
Last Name:AZEVEDO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 162953
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-2953
Mailing Address - Country:US
Mailing Address - Phone:916-335-8105
Mailing Address - Fax:800-450-5024
Practice Address - Street 1:3732 MT DIABLO BLVD
Practice Address - Street 2:SUITE 395
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3632
Practice Address - Country:US
Practice Address - Phone:916-335-8105
Practice Address - Fax:800-450-5024
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51072106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC 51072OtherBOARD OF BEHAVIORAL SCIENCES, LMFT
CA000008462OtherMEDI-CAL PROVIDER #