Healthcare Provider Details

I. General information

NPI: 1861148066
Provider Name (Legal Business Name): EDITH DE JESUS CASILLAS RODRIGUEZ SUDRC #20312
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2022
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 SPAANS DR
GALT CA
95632-8609
US

IV. Provider business mailing address

750 SPAANS DR
GALT CA
95632-8609
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20312
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: