Individual
PHILLA OR
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CMPSS
Contact information
Practice address
333 N SAN JOAQUIN ST, STOCKTON, CA 95202-2954
(209) 683-9300
Mailing address
246 W MAGNOLIA ST, STOCKTON, CA 95203-2538
(209) 683-9300
Taxonomy
Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
Primary
MPSS-CSRTYH
CA
Other
Enumeration date
02/09/2026
Last updated
02/09/2026
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