Healthcare Provider Details

I. General information

NPI: 1184503732
Provider Name (Legal Business Name): RYLEE ANNA RUBALCAVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2025
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 RICHLAND AVE BLDG C-1
CERES CA
95307-4562
US

IV. Provider business mailing address

1130 12TH ST STE A
MODESTO CA
95354-0834
US

V. Phone/Fax

Practice location:
  • Phone: 209-541-2121
  • Fax:
Mailing address:
  • Phone: 209-324-9323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1448910726
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: