Provider Demographics
NPI:1629520044
Name:AMMON, DONNA (RADT-1)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:AMMON
Suffix:
Gender:F
Credentials:RADT-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 HARRIS AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95838-3249
Mailing Address - Country:US
Mailing Address - Phone:916-649-6793
Mailing Address - Fax:916-929-7411
Practice Address - Street 1:650 HOWE AVE # 400B
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-4731
Practice Address - Country:US
Practice Address - Phone:916-993-4131
Practice Address - Fax:916-993-4886
Is Sole Proprietor?:No
Enumeration Date:2016-11-02
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1233011016101YA0400X
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1629520044Medicaid