Healthcare Provider Details

I. General information

NPI: 1356887152
Provider Name (Legal Business Name): ERICA ROXANNE CAUDILLO CDAAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 N 3RD AVE STE N
UPLAND CA
91786-6052
US

IV. Provider business mailing address

167 N 3RD AVE STE N
UPLAND CA
91786-6052
US

V. Phone/Fax

Practice location:
  • Phone: 909-331-8820
  • Fax:
Mailing address:
  • Phone: 909-331-8820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: