Provider Demographics
NPI:1841681020
Name:VIROSTKO, TROY NICHOLAS
Entity type:Individual
Prefix:MR
First Name:TROY
Middle Name:NICHOLAS
Last Name:VIROSTKO
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 1:1350 41ST AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-3934
Mailing Address - Country:US
Mailing Address - Phone:831-428-5577
Mailing Address - Fax:
Practice Address - Street 1:1350 41ST AVE STE 102
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-3934
Practice Address - Country:US
Practice Address - Phone:831-428-5577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR0185136OtherBLUE CROSS / BLUE SHIELD