Healthcare Provider Details

I. General information

NPI: 1154196632
Provider Name (Legal Business Name): ST HUERTA FOUR SQUARE CLINICALS PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2023
Last Update Date: 11/18/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N ARLINGTON AVE STE 340A
RENO NV
89501-1248
US

IV. Provider business mailing address

650 N ROSE DR STE 472
PLACENTIA CA
92870-7513
US

V. Phone/Fax

Practice location:
  • Phone: 775-238-3082
  • Fax: 844-872-5607
Mailing address:
  • Phone: 775-238-3082
  • Fax: 844-872-5607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVEN THOMAS HUERTA
Title or Position: CLINICAL DIRECTOR
Credential: DNP, PMHNP-BC
Phone: 775-238-3082