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General NPI Number Information
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NPI Number | 1790475283
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Entity Type | Individual
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Provider Name | JUSTIN JARRELL SORG RADT
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Gender | Male
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Dates
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Enumeration Date | 05/09/2023
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Last Update Date | 05/09/2023
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Provider Practice Location Address
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Address Line | 132 DAMASCUS DR
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City | PACHECO
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State | CA
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Zip | 94553-2611
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Country | US
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Telephone | 925-497-0534
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Fax |
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Provider Business Mailing Address
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Address Line | 1647 WILLOW PASS RD # 313
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City | CONCORD
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State | CA
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Zip | 94520-2611
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Country | US
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Telephone | 925-497-0534
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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 |
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License Number State |
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