Provider Demographics
NPI:1659827608
Name:POECHHACKER, DOUGLAS
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:
Last Name:POECHHACKER
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 1:4510 PERALTA BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-5755
Mailing Address - Country:US
Mailing Address - Phone:510-713-3202
Mailing Address - Fax:510-713-0684
Practice Address - Street 1:4510 PERALTA BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-5755
Practice Address - Country:US
Practice Address - Phone:510-713-3202
Practice Address - Fax:510-713-0684
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6723-R101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)