Healthcare Provider Details

I. General information

NPI: 1528425147
Provider Name (Legal Business Name): DONNA FREEMAN CANTRELL CADC I CA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 RICHLAND AVE
CERES CA
95307-4562
US

IV. Provider business mailing address

1904 RICHLAND AVE
CERES CA
95307-4562
US

V. Phone/Fax

Practice location:
  • Phone: 209-525-7493
  • Fax: 209-541-2143
Mailing address:
  • Phone: 209-525-7411
  • Fax: 209-541-2083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCI20031217
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License Number1442071
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1442071
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: