Healthcare Provider Details

I. General information

NPI: 1386132785
Provider Name (Legal Business Name): SKYLAR RAINE ZOTIGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 WHISPERING WIND DR
TRACY CA
95377-8119
US

IV. Provider business mailing address

PO BOX 5157
MODESTO CA
95352-5157
US

V. Phone/Fax

Practice location:
  • Phone: 209-832-7756
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License NumberRBT-18-54579
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: