Provider Demographics
NPI:1972744951
Name:STORY, THESSALON SR (CERTIFIED COUNSELOR)
Entity Type:Individual
Prefix:MR
First Name:THESSALON
Middle Name:
Last Name:STORY
Suffix:SR
Gender:M
Credentials:CERTIFIED COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 HARRIS AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95838-3249
Mailing Address - Country:US
Mailing Address - Phone:916-649-6793
Mailing Address - Fax:916-929-7411
Practice Address - Street 1:310 HARRIS AVE STE A
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95838-3249
Practice Address - Country:US
Practice Address - Phone:916-649-6793
Practice Address - Fax:916-929-7411
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-20
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1490101YA0400X
261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA942312757OtherOUTPATIENT DRUG & ALCOHOL TREATMENT