Healthcare Provider Details

I. General information

NPI: 1548131576
Provider Name (Legal Business Name): GERHARD SITUMORANG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2025
Last Update Date: 09/15/2025
Certification Date: 09/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7959 ORANGE AVE
FAIR OAKS CA
95628-5916
US

IV. Provider business mailing address

4822 TOMMAR DR
FAIR OAKS CA
95628-5128
US

V. Phone/Fax

Practice location:
  • Phone: 916-307-0478
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number32748
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: