Healthcare Provider Details
I. General information
NPI: 1518839398
Provider Name (Legal Business Name): MAVIS I. FREEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y
II. Dates (important events)
Enumeration Date: 09/22/2025
Last Update Date: 09/22/2025
Certification Date: 09/21/2025
Deactivation Date:
Reactivation Date:
III. Provider practice location address
3905 SAN PABLO DAM RD
EL SOBRANTE CA
94803-2823
US
IV. Provider business mailing address
3905 SAN PABLO DAM RD
EL SOBRANTE CA
94803-2823
US
V. Phone/Fax
- Phone: 510-390-5467
- Fax: 510-229-3022
- Phone: 510-390-5467
- Fax: 510-229-3022
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | N |
| Taxonomy Code | 163WA2000X |
| Taxonomy | Administrator Registered Nurse |
| License Number | 728470 |
| License Number State | CA |
| # 2 | |
| Primary Taxonomy | N |
| Taxonomy Code | 163WC0200X |
| Taxonomy | Critical Care Medicine Registered Nurse |
| License Number | 28286205C |
| License Number State | IN |
| # 3 | |
| Primary Taxonomy | N |
| Taxonomy Code | 163WC0400X |
| Taxonomy | Case Management Registered Nurse |
| License Number | 728470 |
| License Number State | CA |
| # 4 | |
| Primary Taxonomy | N |
| Taxonomy Code | 163WC1500X |
| Taxonomy | Community Health Registered Nurse |
| License Number | 728470 |
| License Number State | CA |
| # 5 | |
| Primary Taxonomy | N |
| Taxonomy Code | 163WC1600X |
| Taxonomy | Continuing Education/Staff Development Registered Nurse |
| License Number | 728470 |
| License Number State | CA |
| # 6 | |
| Primary Taxonomy | N |
| Taxonomy Code | 163WP0807X |
| Taxonomy | Child & Adolescent Psychiatric/Mental Health Registered Nurse |
| License Number | 728470 |
| License Number State | CA |
| # 7 | |
| Primary Taxonomy | N |
| Taxonomy Code | 163WP0808X |
| Taxonomy | Psychiatric/Mental Health Registered Nurse |
| License Number | 728470 |
| License Number State | CA |
| # 8 | |
| Primary Taxonomy | N |
| Taxonomy Code | 163WP0809X |
| Taxonomy | Adult Psychiatric/Mental Health Registered Nurse |
| License Number | 728470 |
| License Number State | CA |
| # 9 | |
| Primary Taxonomy | N |
| Taxonomy Code | 163WW0000X |
| Taxonomy | Wound Care Registered Nurse |
| License Number | 728470 |
| License Number State | CA |
| # 10 | |
| Primary Taxonomy | N |
| Taxonomy Code | 163WX1500X |
| Taxonomy | Ostomy Care Registered Nurse |
| License Number | 728470 |
| License Number State | CA |
| # 11 | |
| Primary Taxonomy | N |
| Taxonomy Code | 171M00000X |
| Taxonomy | Case Manager/Care Coordinator |
| License Number | 728470 |
| License Number State | CA |
| # 12 | |
| Primary Taxonomy | N |
| Taxonomy Code | 251C00000X |
| Taxonomy | Developmentally Disabled Services Day Training Agency |
| License Number | 728470 |
| License Number State | CA |
| # 13 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 163WC0200X |
| Taxonomy | Critical Care Medicine Registered Nurse |
| License Number | 728470 |
| License Number State | CA |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone:
