Healthcare Provider Details

I. General information

NPI: 1366978124
Provider Name (Legal Business Name): MICHELLE ORTEGA SUDRC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 MISSOURI ST
FAIRFIELD CA
94533-6251
US

IV. Provider business mailing address

2100 NAPA VALLEJO HWY BLDG 253M1M2
NAPA CA
94558-6234
US

V. Phone/Fax

Practice location:
  • Phone: 707-399-9190
  • Fax:
Mailing address:
  • Phone: 707-255-8001
  • Fax: 707-255-8006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12803
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: