Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | 3246 | AL |
NPI | 1003318296 |
---|---|
Provider Name | Olivia Fadul |
First Address | Berkeley, CA 94705-1507 |
Second Address | Berkeley, CA 94705-1507 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/03/2018 |
Last Update Date | 02/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
NA | AM NOT REGISTERED WITH INSURANCE (01) | AL |