Healthcare Provider Details

I. General information

NPI: 1639636285
Provider Name (Legal Business Name): NICOALE WALTERS RADT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2019
Last Update Date: 03/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 SPAANS DR STE CD&F
GALT CA
95632-8609
US

IV. Provider business mailing address

7603 MILES RD
VALLEY SPRINGS CA
95252-9031
US

V. Phone/Fax

Practice location:
  • Phone: 209-744-9909
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1338430219
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: