Healthcare Provider Details

I. General information

NPI: 1962068841
Provider Name (Legal Business Name): FERNANDO OCTAVIO DE ALBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2019
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 N CALIFORNIA ST
STOCKTON CA
95202-1552
US

IV. Provider business mailing address

2495 W MARCH LN
STOCKTON CA
95207-8251
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-8686
  • Fax:
Mailing address:
  • Phone: 209-465-1080
  • Fax: 209-465-2709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: