Healthcare Provider Details

I. General information

NPI: 1831448182
Provider Name (Legal Business Name): MR. ROGELIO BECERRA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2012
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 MDG 101 BODIN CIRCLE
TRAVIS AFB CA
94535-1805
US

IV. Provider business mailing address

60 MDG 101 BODIN CIRCLE
TRAVIS AFB CA
94535
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-3000
  • Fax:
Mailing address:
  • Phone: 707-423-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number253005
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: