Healthcare Provider Details

I. General information

NPI: 1730825407
Provider Name (Legal Business Name): ASHLEY NICOLE OBREGON RADT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2022
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20302 FLANAGAN ROAD
TRABUCO CANYON CA
92679
US

IV. Provider business mailing address

2221 E VISTA CANYON RD
ORANGE CA
92867-1745
US

V. Phone/Fax

Practice location:
  • Phone: 818-582-8832
  • Fax: 818-582-8836
Mailing address:
  • Phone: 562-360-3291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1467520522
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: