Healthcare Provider Details

I. General information

NPI: 1447177209
Provider Name (Legal Business Name): JOSHUA DAVID CHRISTIE SUDRC I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 TOYANZA DRIVE
SAN ANDREAS CA
95249-9713
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: 209-754-6559
Mailing address:
  • Phone: 209-754-6955
  • Fax: 209-754-6559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number25974
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: