Healthcare Provider Details

I. General information

NPI: 1033816780
Provider Name (Legal Business Name): DRAKE CAUDILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11111 BLOOMFIELD AVE
SANTA FE SPRINGS CA
90670-4655
US

IV. Provider business mailing address

12070 TELEGRAPH RD
SANTA FE SPRINGS CA
90670-3771
US

V. Phone/Fax

Practice location:
  • Phone: 562-906-2685
  • Fax:
Mailing address:
  • Phone: 562-777-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: