Healthcare Provider Details

I. General information

NPI: 1912441387
Provider Name (Legal Business Name): VICTORIA CALLAWAY BAASCH RADTI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2016
Last Update Date: 12/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2844 COLOMA ST
PLACERVILLE CA
95667-4406
US

IV. Provider business mailing address

2640 CAMBRIDGE RD APT 86
CAMERON PARK CA
95682-9295
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-9240
  • Fax: 530-626-8992
Mailing address:
  • Phone: 916-416-4837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1224420316
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: