Healthcare Provider Details

I. General information

NPI: 1154443190
Provider Name (Legal Business Name): FONDA HILL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 N CALIFORNIA ST
STOCKTON CA
95202-1552
US

IV. Provider business mailing address

1212 N CALIFORNIA ST
STOCKTON CA
95202-1552
US

V. Phone/Fax

Practice location:
  • Phone: 209-952-7524
  • Fax: 209-953-7526
Mailing address:
  • Phone: 209-953-7524
  • Fax: 209-953-7526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberH0501011505
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: