Provider Demographics
NPI:1659017135
Name:CERVANTES, INGRID (SUDRC)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:CERVANTES
Suffix:
Gender:F
Credentials:SUDRC
Other - Prefix:
Other - First Name:INGRID
Other - Middle Name:
Other - Last Name:CERVANTES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:620 N AURORA ST STE 1
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-2276
Mailing Address - Country:US
Mailing Address - Phone:209-468-8356
Mailing Address - Fax:
Practice Address - Street 1:620 N AURORA ST STE 1
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2276
Practice Address - Country:US
Practice Address - Phone:209-468-8356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA13268Medicaid