Healthcare Provider Details

I. General information

NPI: 1972416709
Provider Name (Legal Business Name): SAGE PADILLA CCC-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 TENNIS LN
TRACY CA
95376-5316
US

IV. Provider business mailing address

1600 TENNIS LN
TRACY CA
95376-5316
US

V. Phone/Fax

Practice location:
  • Phone: 209-830-3345
  • Fax:
Mailing address:
  • Phone: 209-830-3345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number33016
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: