Basic Information
| Provider Information | |||||||||
| NPI: | 1346765351 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSPACE HEALTH | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | WELLSPACE HEALTH STRATEGIES FOR CHANGE-NORTH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1820 J ST | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958113010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165505481 | ||||||||
| FaxNumber: | 9165203921 | ||||||||
| Practice Location | |||||||||
| Address1: | 4441 AUBURN BLVD STE E | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958414139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164735764 | ||||||||
| FaxNumber: | 9164735766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2017 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | PORTEUS | ||||||||
| AuthorizedOfficialFirstName: | ALASDAIR | ||||||||
| AuthorizedOfficialMiddleName: | JONATHAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9163138413 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.