Healthcare Provider Details

I. General information

NPI: 1255147310
Provider Name (Legal Business Name): ELEXUS LAYTERION GREENE RAD-T
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

1095 E TABOR AVE APT B
FAIRFIELD CA
94533-4190
US

IV. Provider business mailing address

609 JEFFERSON ST STE B
FAIRFIELD CA
94533-6228
US

V. Phone/Fax

Practice location:
  • Phone: 707-718-4872
  • Fax:
Mailing address:
  • Phone: 707-718-4872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1584231024
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: