Provider Demographics
NPI:1760264915
Name:RAESE, DAVID (SUDRC#15389)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:RAESE
Suffix:
Gender:M
Credentials:SUDRC#15389
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 SYLVAN AVE STE C103
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1687
Mailing Address - Country:US
Mailing Address - Phone:209-758-7477
Mailing Address - Fax:866-875-7351
Practice Address - Street 1:1101 SYLVAN AVE STE C103
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-1687
Practice Address - Country:US
Practice Address - Phone:209-758-7477
Practice Address - Fax:866-875-7351
Is Sole Proprietor?:No
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15389101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)