Provider Demographics
NPI:1295364230
Name:PACE, ROBERT JOHN (RADT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JOHN
Last Name:PACE
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W SCHOOL AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-4925
Mailing Address - Country:US
Mailing Address - Phone:559-625-4100
Mailing Address - Fax:
Practice Address - Street 1:120 W SCHOOL AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-4925
Practice Address - Country:US
Practice Address - Phone:559-625-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1293500318101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00850200517OtherCCAPP