Basic Information
| Provider Information | |||||||||
| NPI: | 1275287161 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FEDOROVA | ||||||||
| FirstName: | VALERIYA | ||||||||
| MiddleName: | |||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 E BIDWELL ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | FOLSOM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956303565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169835915 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1301 E BIDWELL ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | FOLSOM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956303565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169835915 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2022 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 15434 | CA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 15434 | 01 | CA | LICENSE | OTHER |