Provider Demographics
NPI:1659245231
Name:SACULLA, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:SACULLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 DAVE BRUBECK WAY APT 2
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-1864
Mailing Address - Country:US
Mailing Address - Phone:209-612-5336
Mailing Address - Fax:
Practice Address - Street 1:650 DAVE BRUBECK WAY APT 2
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204
Practice Address - Country:US
Practice Address - Phone:209-612-5336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-06
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD8070634106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty