Provider Demographics
NPI:1497388391
Name:NEELY, DAVID (BA RADT I)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:NEELY
Suffix:
Gender:M
Credentials:BA RADT I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1036 GRAY PINE WAY
Mailing Address - Street 2:
Mailing Address - City:SHASTA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:96019-9600
Mailing Address - Country:US
Mailing Address - Phone:530-515-4883
Mailing Address - Fax:
Practice Address - Street 1:1465 VICTOR AVE STE B
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96003-4856
Practice Address - Country:US
Practice Address - Phone:530-338-0087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA131202101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)