Healthcare Provider Details

I. General information

NPI: 1134940935
Provider Name (Legal Business Name): SCOTT CLARK HOSTETTER-LEWIS PSYCHIATRIC TECH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3211 COHASSET RD STE 130
CHICO CA
95973-5403
US

IV. Provider business mailing address

3211 COHASSET RD STE 130
CHICO CA
95973-5403
US

V. Phone/Fax

Practice location:
  • Phone: 530-552-5058
  • Fax: 530-879-3823
Mailing address:
  • Phone: 530-321-4608
  • Fax: 530-879-3823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number42893
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: