Provider Demographics
NPI:1023520590
Name:SAUCEDA, DEREK MICHAEL (CATC)
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:MICHAEL
Last Name:SAUCEDA
Suffix:
Gender:M
Credentials:CATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W BIANCHI RD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-7132
Mailing Address - Country:US
Mailing Address - Phone:209-644-6319
Mailing Address - Fax:
Practice Address - Street 1:1222 MONACO CT STE 28
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6742
Practice Address - Country:US
Practice Address - Phone:209-644-6328
Practice Address - Fax:209-644-6308
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-24
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390017AN101YA0400X
CA179702101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA390017ANOtherCOURT ORDERED ORSELF PAY