Healthcare Provider Details

I. General information

NPI: 1609533371
Provider Name (Legal Business Name): ROBERT BRADLEY HUSTON JR. RADT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2021
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12490 ALTA MESA RD
HERALD CA
95638-8409
US

IV. Provider business mailing address

500 22ND ST
SACRAMENTO CA
95816-3503
US

V. Phone/Fax

Practice location:
  • Phone: 209-748-2470
  • Fax:
Mailing address:
  • Phone: 209-748-2470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: