Provider Demographics
NPI:1164019907
Name:WOLDEMARIAM, CALEB ABEBE
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:ABEBE
Last Name:WOLDEMARIAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5628 BANTEER WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-8669
Mailing Address - Country:US
Mailing Address - Phone:925-628-2662
Mailing Address - Fax:
Practice Address - Street 1:800 S BROADWAY STE 310
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5218
Practice Address - Country:US
Practice Address - Phone:925-264-1902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician