Provider Demographics
NPI:1972636603
Name:DE LA CERDA, CARLOS
Entity Type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:
Last Name:DE LA CERDA
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:CHARLES
Other - Middle Name:
Other - Last Name:DE LA CERDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2800 BRADEN AVE # 321
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-0648
Mailing Address - Country:US
Mailing Address - Phone:209-404-2101
Mailing Address - Fax:
Practice Address - Street 1:2800 BRADEN AVE # 321
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-0648
Practice Address - Country:US
Practice Address - Phone:209-404-2101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA0683425101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)