Provider Demographics
NPI:1689241705
Name:DONATO, JUSTIN CHARLES
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:CHARLES
Last Name:DONATO
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 1:1724 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-4336
Mailing Address - Country:US
Mailing Address - Phone:209-321-2163
Mailing Address - Fax:
Practice Address - Street 1:1025 ATLANTIC AVE STE 101
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1188
Practice Address - Country:US
Practice Address - Phone:209-321-2163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician