Healthcare Provider Details

I. General information

NPI: 1669976767
Provider Name (Legal Business Name): GABRIEL JESS SILVA SUDCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2018
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 W CENTER ST STE 12A
MANTECA CA
95337-7327
US

IV. Provider business mailing address

955 W CENTER ST STE 12A
MANTECA CA
95337
US

V. Phone/Fax

Practice location:
  • Phone: 209-239-9600
  • Fax:
Mailing address:
  • Phone: 209-239-9600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number9933
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: