Healthcare Provider Details

I. General information

NPI: 1649844846
Provider Name (Legal Business Name): AUDRA RENEE CROCKER RADT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 SPAANS DR STE C
GALT CA
95632-8609
US

IV. Provider business mailing address

750 SPAANS DR STE C
GALT CA
95632-8609
US

V. Phone/Fax

Practice location:
  • Phone: 209-744-9909
  • Fax: 209-744-9910
Mailing address:
  • Phone: 209-744-9909
  • Fax: 209-744-8810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1429190521
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: