Provider Demographics
NPI:1164085304
Name:TABOADA, RAYMOND J JR
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:J
Last Name:TABOADA
Suffix:JR
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 1:1001 SNEATH LN
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-2308
Mailing Address - Country:US
Mailing Address - Phone:650-244-1444
Mailing Address - Fax:
Practice Address - Street 1:1001 SNEATH LN
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-2308
Practice Address - Country:US
Practice Address - Phone:650-244-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-14
Last Update Date:2019-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)