Healthcare Provider Details

I. General information

NPI: 1720401185
Provider Name (Legal Business Name): URSULA STALLWORTH C.M.P
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2014
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 LAKE BLVD STE 237
DAVIS CA
95616-2687
US

IV. Provider business mailing address

7917 SENECA WAY
ANTELOPE CA
95843-2185
US

V. Phone/Fax

Practice location:
  • Phone: 916-613-0524
  • Fax:
Mailing address:
  • Phone: 916-604-2188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number47317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: