Basic Information
| Provider Information | |||||||||
| NPI: | 1629520044 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMMON | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | |||||||||
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| Credential: | RADT-1 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 HARRIS AVE | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958383249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166496793 | ||||||||
| FaxNumber: | 9169297411 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 HOWE AVE # 400B | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958254731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169934131 | ||||||||
| FaxNumber: | 9169934886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2016 | ||||||||
| LastUpdateDate: | 09/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | R1233011016 | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101Y00000X | CA | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 1629520044 | 05 | CA | MEDICAID |