Provider Demographics
NPI:1952061152
Name:DETURCK, ALEX JOHN
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:JOHN
Last Name:DETURCK
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 1:1117 VISTA DEL LAGO
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-4832
Mailing Address - Country:US
Mailing Address - Phone:650-474-1266
Mailing Address - Fax:
Practice Address - Street 1:1255 KENDALL RD
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-8750
Practice Address - Country:US
Practice Address - Phone:805-781-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health