Healthcare Provider Details

I. General information

NPI: 1124781778
Provider Name (Legal Business Name): EDWARD DENNIS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2021
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 SUNRISE AVE STE 300
ROSEVILLE CA
95661-4106
US

IV. Provider business mailing address

10041 LODE LINE WAY
GRASS VALLEY CA
95949-9296
US

V. Phone/Fax

Practice location:
  • Phone: 530-470-2425
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number37564
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: