Basic Information
Provider Information | |||||||||
NPI: | 1770128431 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SARACENO | ||||||||
FirstName: | KATHERINE | ||||||||
MiddleName: | ROSE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FIGUEROA SARACENO | ||||||||
OtherFirstName: | KATHERINE | ||||||||
OtherMiddleName: | ROSE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 26072 CASCADE ST | ||||||||
Address2: |   | ||||||||
City: | HAYWARD | ||||||||
State: | CA | ||||||||
PostalCode: | 945442634 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4247890949 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 26081 MOCINE AVE | ||||||||
Address2: |   | ||||||||
City: | HAYWARD | ||||||||
State: | CA | ||||||||
PostalCode: | 945442923 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5108815921 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2019 | ||||||||
LastUpdateDate: | 11/16/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor |   |
ID Information
ID | Type | State | Issuer | Description | UNKNOWN | 05 | CA |   | MEDICAID |