Basic Information
| Provider Information | |||||||||
| NPI: | 1215131206 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SIERRA COUNCIL ON ALCOHOLISM & DRUG DEPENDENCE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 11960 HERITAGE OAK PL | ||||||||
| Address2: | SUITE 15 | ||||||||
| City: | AUBURN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956032401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308851961 | ||||||||
| FaxNumber: | 5308850713 | ||||||||
| Practice Location | |||||||||
| Address1: | 11960 HERITAGE OAK PL | ||||||||
| Address2: | SUITE 15 | ||||||||
| City: | AUBURN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956032401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308851961 | ||||||||
| FaxNumber: | 5308850713 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | DEBORA | ||||||||
| AuthorizedOfficialMiddleName: | ANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHEIF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9167978989 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 310001EN | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 31 AB | 01 | CA | MEDI-CAL | OTHER |