=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780495366
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BHIPIN B PRASAD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2025
-----------------------------------------------------
Last Update Date | 01/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10898 BOESSOW RD
-----------------------------------------------------
City | GALT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95632-8451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-412-2389
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2701 MARLBORO PL
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95355-4641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-635-0059
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------