Healthcare Provider Details

I. General information

NPI: 1841670130
Provider Name (Legal Business Name): CLIFF OWL III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 07/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4175 LAKESIDE DRIVE SUITE 110
RICHMOND CA
94806
US

IV. Provider business mailing address

2001 28TH STREET
OAKLAND CA
94608
US

V. Phone/Fax

Practice location:
  • Phone: 510-262-6551
  • Fax: 510-222-7085
Mailing address:
  • Phone: 828-557-2264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: