Healthcare Provider Details

I. General information

NPI: 1811640964
Provider Name (Legal Business Name): JOHNNY ASENCION CUESTAS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2022
Last Update Date: 01/29/2022
Certification Date: 01/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 57TH ST STE 572
SACRAMENTO CA
95819-3327
US

IV. Provider business mailing address

836 57TH ST STE 572
SACRAMENTO CA
95819-3327
US

V. Phone/Fax

Practice location:
  • Phone: 916-460-1822
  • Fax:
Mailing address:
  • Phone: 916-460-1822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number100299
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: