Provider Demographics
NPI:1811982267
Name:SAUCEDO, CARLOS FERNANDO (PH D)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:FERNANDO
Last Name:SAUCEDO
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11260 WILBUR AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-2450
Mailing Address - Country:US
Mailing Address - Phone:818-362-5454
Mailing Address - Fax:818-362-1722
Practice Address - Street 1:11260 WILBUR AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91326-2450
Practice Address - Country:US
Practice Address - Phone:818-362-5454
Practice Address - Fax:818-362-1722
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7298103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP7298AMedicare ID - Type Unspecified