Healthcare Provider Details

I. General information

NPI: 1689220477
Provider Name (Legal Business Name): CARL LEONARD FESSENDEN CADC-II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 09/29/2026
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1974 WINCHESTER PL
FAIRFIELD CA
94533-3618
US

IV. Provider business mailing address

1974 WINCHESTER PL
FAIRFIELD CA
94533-3618
US

V. Phone/Fax

Practice location:
  • Phone: 707-290-1166
  • Fax:
Mailing address:
  • Phone: 707-290-1166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: