Healthcare Provider Details

I. General information

NPI: 1104642974
Provider Name (Legal Business Name): NATALIE FROST SUDRC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2024
Last Update Date: 12/04/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 W LEXINGTON AVE
EL CAJON CA
92020-4465
US

IV. Provider business mailing address

823 GATEWAY CENTER WAY
SAN DIEGO CA
92102-4541
US

V. Phone/Fax

Practice location:
  • Phone: 619-255-5499
  • Fax:
Mailing address:
  • Phone: 619-515-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16954
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: