Healthcare Provider Details

I. General information

NPI: 1356783369
Provider Name (Legal Business Name): DAVID BENJAMIN LAETHEM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2013
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9121 FOLSOM BLVD
SACRAMENTO CA
95826-2473
US

IV. Provider business mailing address

1749 CARMELO DR
CARMICHAEL CA
95608-5718
US

V. Phone/Fax

Practice location:
  • Phone: 916-516-1865
  • Fax:
Mailing address:
  • Phone: 916-261-1645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: