Healthcare Provider Details

I. General information

NPI: 1538537535
Provider Name (Legal Business Name): DIMITRIA UQDAH RADT1
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 E PALMDALE BLVD
PALMDALE CA
93550-4750
US

IV. Provider business mailing address

1050 E PALMDALE BLVD
PALMDALE CA
93550-4750
US

V. Phone/Fax

Practice location:
  • Phone: 661-208-4699
  • Fax: 661-208-4761
Mailing address:
  • Phone: 661-208-4699
  • Fax: 661-208-4761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRS0245
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: