Healthcare Provider Details

I. General information

NPI: 1912825563
Provider Name (Legal Business Name): DALLAS PRIVETT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2844 COLOMA ST
PLACERVILLE CA
95667-4406
US

IV. Provider business mailing address

344 PLACERVILLE DR
PLACERVILLE CA
95667-3920
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-9240
  • Fax:
Mailing address:
  • Phone: 530-957-5059
  • Fax:

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: