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110 Blue Ravine Rd Ste 104 Folsom CA 95630-4712 | |
| (916) 234-6585 | |
| (916) 805-5145 |
| Full Name | |
|---|---|
| Speciality | Psychologist - Clinical |
| Location | 110 Blue Ravine Rd Ste 104, Folsom, California |
| Authorized Official Name and Position | Nicolette Bautista (CEO) |
| Authorized Official Contact | 9162346585 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
110 Blue Ravine Rd Ste 104 Folsom CA 95630-4712 Ph: (916) 505-4419 | 110 Blue Ravine Rd Ste 104 Folsom CA 95630-4712 Ph: (916) 234-6585 |
| NPI Number | 1063278943 |
|---|---|
| Provider Enumeration Date | 02/27/2024 |
| Last Update Date | 01/09/2025 |
| Certification Date | 01/09/2025 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1063278943 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | (* (Not Available)) | Primary |
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