Healthcare Provider Details

I. General information

NPI: 1881240539
Provider Name (Legal Business Name): DUSTIN A STEPHENSON CCAPP REGISTRATION
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 03/27/2020
Certification Date: 03/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 J ST
SACRAMENTO CA
95811-3010
US

IV. Provider business mailing address

3 SOMER RIDGE DR APT 137
ROSEVILLE CA
95661-5255
US

V. Phone/Fax

Practice location:
  • Phone: 916-313-8434
  • Fax:
Mailing address:
  • Phone: 916-710-9863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: