=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003115775
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. ANTE BARICEVIC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2011
-----------------------------------------------------
Last Update Date | 08/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3321 POWER INN RD
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95826-3890
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-874-9883
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9279 BLUE OAK DR
-----------------------------------------------------
City | ORANGEVALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95662-5326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-501-0893
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------