Healthcare Provider Details

I. General information

NPI: 1609346402
Provider Name (Legal Business Name): DOUGLASS RICHARDSON MSPSY, CADC III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N AURORA ST STE 1
STOCKTON CA
95202-2276
US

IV. Provider business mailing address

12935 ALCOSTA BLVD UNIT 3882
SAN RAMON CA
94583-6181
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-9370
  • Fax:
Mailing address:
  • Phone: 209-696-1125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberBII00640223
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License NumberBII00640223
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberBII00640223
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: