Basic Information
| Provider Information | |||||||||
| NPI: | 1568979656 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADDISON | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | DARKO | ||||||||
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| Mailing Information | |||||||||
| Address1: | ALEXANDERADDISON@DBHSBCOUNTYGOV 8320 E GILBERT ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924150001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093877200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | ALEXANDERADDISON@DBHSBCOUNTYGOV 8320 E GILBERT ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924150001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093877200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2018 | ||||||||
| LastUpdateDate: | 06/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 734124 | CA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.