Provider Demographics
NPI:1770323255
Name:VIBOOLSITTISERI, AUDRIC NOAH
Entity type:Individual
Prefix:
First Name:AUDRIC
Middle Name:NOAH
Last Name:VIBOOLSITTISERI
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 1:854 W BATTLEMENT PKWY APT C106
Mailing Address - Street 2:
Mailing Address - City:PARACHUTE
Mailing Address - State:CO
Mailing Address - Zip Code:81635-9378
Mailing Address - Country:US
Mailing Address - Phone:970-366-1763
Mailing Address - Fax:
Practice Address - Street 1:3824 BUELL ST STE A2
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94619-2861
Practice Address - Country:US
Practice Address - Phone:510-422-3959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician