Healthcare Provider Details

I. General information

NPI: 1962192823
Provider Name (Legal Business Name): AIMEE RENE CARDOZA RADT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2023
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 S FAIRMONT AVE
LODI CA
95240-3958
US

IV. Provider business mailing address

3131 INDEPENDENCE DR
LIVERMORE CA
94551-7595
US

V. Phone/Fax

Practice location:
  • Phone: 209-744-9909
  • Fax: 209-744-9910
Mailing address:
  • Phone: 888-474-1601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberR1506460523
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1506460523
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: