Healthcare Provider Details

I. General information

NPI: 1174191209
Provider Name (Legal Business Name): ANTHONY DIBELLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 I ST STE 2002ND
MODESTO CA
95354-1110
US

IV. Provider business mailing address

1601 I ST STE 2002ND
MODESTO CA
95354-1110
US

V. Phone/Fax

Practice location:
  • Phone: 888-376-6246
  • Fax:
Mailing address:
  • Phone: 209-525-6225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: