Provider Demographics
NPI:1265923478
Name:AUGUSTUS, JAMES III
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:AUGUSTUS
Suffix:III
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 1:1115 14TH ST
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-1003
Mailing Address - Country:US
Mailing Address - Phone:209-572-2589
Mailing Address - Fax:
Practice Address - Street 1:1115 14TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-1003
Practice Address - Country:US
Practice Address - Phone:209-572-2589
Practice Address - Fax:209-572-1461
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18-54036106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician