Healthcare Provider Details

I. General information

NPI: 1477145480
Provider Name (Legal Business Name): THE DODAAW RANCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2021
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 COOK AVENUE
MODESTO CA
95358
US

IV. Provider business mailing address

2404 COOK AVENUE
MODESTO CA
95358
US

V. Phone/Fax

Practice location:
  • Phone: 209-567-2455
  • Fax:
Mailing address:
  • Phone: 209-567-2455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. WENDY HANNAH DYANN MILLER
Title or Position: EXECUTIVE DIRECTOR
Credential: MSW, ACSW, CADAC-CAS
Phone: 209-568-7544