Healthcare Provider Details

I. General information

NPI: 1659722486
Provider Name (Legal Business Name): STEPHEN RYAN FAILLE MSW, ASW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 HENNESSEY WAY
PLUMAS LAKE CA
95961-9224
US

IV. Provider business mailing address

PO BOX 153802
SAN DIEGO CA
92195-3000
US

V. Phone/Fax

Practice location:
  • Phone: 194-567-3376
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW102825
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1239753
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: