Healthcare Provider Details

I. General information

NPI: 1760669717
Provider Name (Legal Business Name): MR. JAMES M CUDZIOL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1979 BERKESEY LN
VALLEY SPRINGS CA
95252
US

IV. Provider business mailing address

PO BOX 1640
WEAVERVILLE CA
96093-1640
US

V. Phone/Fax

Practice location:
  • Phone: 209-772-3765
  • Fax:
Mailing address:
  • Phone: 530-623-1362
  • Fax: 530-623-1447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number77132
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: