Healthcare Provider Details

I. General information

NPI: 1336403708
Provider Name (Legal Business Name): SIERRA STONEGATE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 06/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3657 GOLDENSTAR ST
PLUMAS LAKE CA
95961-8746
US

IV. Provider business mailing address

3657 GOLDENSTAR ST
PLUMAS LAKE CA
95961-8746
US

V. Phone/Fax

Practice location:
  • Phone: 916-475-9586
  • Fax:
Mailing address:
  • Phone: 916-475-9586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number57436
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number57436
License Number StateCA

VIII. Authorized Official

Name: SAM VINEY
Title or Position: THERAPIST
Credential: MA, MFT
Phone: 916-475-8590