Provider Demographics
NPI:1639669070
Name:MERSAROLI, SIOBAN REGINA
Entity Type:Individual
Prefix:
First Name:SIOBAN
Middle Name:REGINA
Last Name:MERSAROLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1373 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3248
Mailing Address - Country:US
Mailing Address - Phone:209-597-2591
Mailing Address - Fax:
Practice Address - Street 1:1947 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-6029
Practice Address - Country:US
Practice Address - Phone:209-463-0807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-11
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1265630917101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YA0400XMedicaid