Provider Demographics
NPI:1881167971
Name:GADDIS, RONNIE LEE JR (LVN)
Entity type:Individual
Prefix:MRS
First Name:RONNIE
Middle Name:LEE
Last Name:GADDIS
Suffix:JR
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 MACARTHUR BLVD APT 208
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-3186
Mailing Address - Country:US
Mailing Address - Phone:714-910-9146
Mailing Address - Fax:
Practice Address - Street 1:255 MACARTHUR BLVD APT 208
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-3186
Practice Address - Country:US
Practice Address - Phone:714-910-9146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-10
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty