Healthcare Provider Details

I. General information

NPI: 1851191290
Provider Name (Legal Business Name): DARYL BOUIE CHW, PSS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2025
Last Update Date: 09/13/2025
Certification Date: 09/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 MUCKELEMI ST STE B
SAN JUAN BAUTISTA CA
95045-3073
US

IV. Provider business mailing address

930 CASANOVA AVE APT 34
MONTEREY CA
93940-6821
US

V. Phone/Fax

Practice location:
  • Phone: 831-275-8456
  • Fax:
Mailing address:
  • Phone: 831-275-8456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-SEVYIT
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: