Healthcare Provider Details

I. General information

NPI: 1043959059
Provider Name (Legal Business Name): LELA DANIELLE FORD HETZER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LELA DANIELLE FORD SUDCC

II. Dates (important events)

Enumeration Date: 05/31/2022
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 TOYANZA DR
SAN ANDREAS CA
95249-0000
US

IV. Provider business mailing address

891 MOUNTAIN RANCH RD
SAN ANDREAS CA
95249-9713
US

V. Phone/Fax

Practice location:
  • Phone: 209-754-6555
  • Fax:
Mailing address:
  • Phone: 209-754-6555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17873
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: