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General NPI Number Information
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NPI Number | 1144794991
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Entity Type | Individual
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Provider Name | LISA LEETTA JEWETT RADT
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Gender | Female
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Dates
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Enumeration Date | 01/15/2019
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Last Update Date | 01/15/2019
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Provider Practice Location Address
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Address Line | 750 SPAANS DR STE CD&F
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City | GALT
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State | CA
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Zip | 95632-8609
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Country | US
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Telephone | 209-744-9909
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Fax |
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Provider Business Mailing Address
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Address Line | 2937 TOGNINALI LN
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City | STOCKTON
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State | CA
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Zip | 95206-6028
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Country | US
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Telephone | 408-508-2178
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | R1310170618
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License Number State | CA
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