Healthcare Provider Details

I. General information

NPI: 1639450398
Provider Name (Legal Business Name): SCOTT MARION RALSTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2011
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

837 ADDISON ST
BERKELEY CA
94710-2047
US

IV. Provider business mailing address

526 S SAN PEDRO ST
LOS ANGELES CA
90013-2102
US

V. Phone/Fax

Practice location:
  • Phone: 510-981-4100
  • Fax:
Mailing address:
  • Phone: 213-488-9559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number75965
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: