Healthcare Provider Details

I. General information

NPI: 1689864514
Provider Name (Legal Business Name): SAMUEL JOSEPH YEPEZ JR. CCAPP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 03/08/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3155 KEARNY STREET #150
FREMONT CA
94538
US

IV. Provider business mailing address

1231N ELGIN STREET
SAN LEANDRO CA
94578
US

V. Phone/Fax

Practice location:
  • Phone: 844-682-7215
  • Fax: 510-771-9910
Mailing address:
  • Phone: 510-586-1744
  • Fax: 510-535-2346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number60986
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC041880118
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: