Basic Information
| Provider Information | |||||||||
| NPI: | 1467661769 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAYDER | ||||||||
| FirstName: | MARCY | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S.W., L.C.S.W. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HIXSON | ||||||||
| OtherFirstName: | MARCY | ||||||||
| OtherMiddleName: | RENE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | S.W.A. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 622 | ||||||||
| Address2: | |||||||||
| City: | DAVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956170622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307567542 | ||||||||
| FaxNumber: | 9168759970 | ||||||||
| Practice Location | |||||||||
| Address1: | 1784 PICASSO AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | DAVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956180551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307567542 | ||||||||
| FaxNumber: | 5307562931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 05/21/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 23058 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.