MEDICARE: READY4CHANGE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1275991887
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	READY4CHANGE

Provider Business Mailing Address
First Line	:	1221 SOUTH AVE
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95838-4464
Country	:	US
Telephone Number	:	916-566-3450
Fax Number	:

Provider Business Practice Location Address
First Line	:	1221 SOUTH AVE
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95838-4464
Country	:	US
Telephone Number	:	916-566-3450
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. LEO A VASQUEZ
Credential	:	BSW
Telephone Number	:	916-821-9090

Provider Enumeration Date	:	02/10/2016
Last Update Date	:	03/04/2016

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Directions to “READY4CHANGE ” Practice Location

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