Healthcare Provider Details

I. General information

NPI: 1437068335
Provider Name (Legal Business Name): BRENT SOURA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 SCENIC AVE
BERKELEY CA
94709-1395
US

IV. Provider business mailing address

2323 HEARST AVE
BERKELEY CA
94709-1319
US

V. Phone/Fax

Practice location:
  • Phone: 510-548-7270
  • Fax:
Mailing address:
  • Phone: 510-526-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1611870525
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: