Provider Demographics
NPI:1932387297
Name:BEJARANO, LYDIA ELAINE
Entity Type:Individual
Prefix:MS
First Name:LYDIA
Middle Name:ELAINE
Last Name:BEJARANO
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 1:1100 KANSAS AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95351-1596
Mailing Address - Country:US
Mailing Address - Phone:209-579-1151
Mailing Address - Fax:
Practice Address - Street 1:1116 ALICE ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5905
Practice Address - Country:US
Practice Address - Phone:209-578-3132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-08
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1617101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)