Healthcare Provider Details

I. General information

NPI: 1750178257
Provider Name (Legal Business Name): KRAIG ROSCOE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 06/07/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6135 KING RD STE B
LOOMIS CA
95650-8877
US

IV. Provider business mailing address

6135 KING RD STE B
LOOMIS CA
95650-8877
US

V. Phone/Fax

Practice location:
  • Phone: 916-676-7405
  • Fax:
Mailing address:
  • Phone: 916-676-7405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number129250
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: