Healthcare Provider Details

I. General information

NPI: 1396547741
Provider Name (Legal Business Name): ERIC ROLAND WITHERELL PPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 MCCOURTNEY RD STE E
GRASS VALLEY CA
95949-7423
US

IV. Provider business mailing address

960 MCCOURTNEY RD STE E
GRASS VALLEY CA
95949-7423
US

V. Phone/Fax

Practice location:
  • Phone: 530-272-4008
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: