Healthcare Provider Details

I. General information

NPI: 1255782983
Provider Name (Legal Business Name): MYRRA MARIE STOCKMAN CATCI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MYRRA MARIE ALO CATCI

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4750 PALM AVE
RIVERSIDE CA
92501-4012
US

IV. Provider business mailing address

4750 PALM AVE
RIVERSIDE CA
92501-4012
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-0021
  • Fax: 951-686-0026
Mailing address:
  • Phone: 951-686-0021
  • Fax: 951-686-0026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number112518
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: