Healthcare Provider Details

I. General information

NPI: 1063814002
Provider Name (Legal Business Name): JANELL CAUSTRTIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2014
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

559 MENDOCINO CT
ATWATER CA
95301-4230
US

IV. Provider business mailing address

559 MENDOCINO CT
ATWATER CA
95301-4230
US

V. Phone/Fax

Practice location:
  • Phone: 209-357-5200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: