Provider Demographics
NPI:1811694862
Name:ACACIO, ELIJAH RICHARD
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:RICHARD
Last Name:ACACIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:768 ELM AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-3403
Mailing Address - Country:US
Mailing Address - Phone:650-228-3994
Mailing Address - Fax:
Practice Address - Street 1:170 S SPRUCE AVE STE 200
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-4557
Practice Address - Country:US
Practice Address - Phone:415-855-5580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-10
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor