Provider Demographics
NPI:1780187054
Name:SOBOCINSKI, BRIAN JORDAN (RADT-1)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JORDAN
Last Name:SOBOCINSKI
Suffix:
Gender:M
Credentials:RADT-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 BEACH CT.
Mailing Address - Street 2:
Mailing Address - City:LOTUS
Mailing Address - State:CA
Mailing Address - Zip Code:95651-4441
Mailing Address - Country:US
Mailing Address - Phone:530-626-7252
Mailing Address - Fax:
Practice Address - Street 1:2986 COLOMA ST
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-4441
Practice Address - Country:US
Practice Address - Phone:530-748-3706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CACI27210419101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)