Healthcare Provider Details

I. General information

NPI: 1053973206
Provider Name (Legal Business Name): MICHAEL LEE CHIDESTER JR. CATC-I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 THORNTON AVE
NEWARK CA
94560-3734
US

IV. Provider business mailing address

6330 THORNTON AVE
NEWARK CA
94560-3734
US

V. Phone/Fax

Practice location:
  • Phone: 510-792-4357
  • Fax:
Mailing address:
  • Phone: 510-792-4357
  • Fax: 510-745-1693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: