Basic Information
| Provider Information | |||||||||
| NPI: | 1932757416 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CACCIOTTI | ||||||||
| FirstName: | SERGIO | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3120 4TH ST | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904055471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105703769 | ||||||||
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| Practice Location | |||||||||
| Address1: | 204 HAMPTON DR | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902912623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103966468 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2019 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.