Provider Demographics
NPI:1417616236
Name:STATON, CEDRIC ANTRON (LPCC)
Entity Type:Individual
Prefix:MR
First Name:CEDRIC
Middle Name:ANTRON
Last Name:STATON
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2772 PIANTINO CIR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4736
Mailing Address - Country:US
Mailing Address - Phone:704-492-9595
Mailing Address - Fax:
Practice Address - Street 1:2525 CAMINO DEL RIO S STE 313
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3784
Practice Address - Country:US
Practice Address - Phone:442-322-8143
Practice Address - Fax:619-598-0594
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2022-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11040101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALPCC11040OtherCALIFORNIA BOARD OF BEHAVIORAL SCIENCES