Provider Demographics
NPI:1154128965
Name:SULAMO, AUDRA
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:SULAMO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 KORALLA WAY
Mailing Address - Street 2:
Mailing Address - City:GALT
Mailing Address - State:CA
Mailing Address - Zip Code:95632-3413
Mailing Address - Country:US
Mailing Address - Phone:209-912-9021
Mailing Address - Fax:
Practice Address - Street 1:907 KORALLA WAY
Practice Address - Street 2:
Practice Address - City:GALT
Practice Address - State:CA
Practice Address - Zip Code:95632-3413
Practice Address - Country:US
Practice Address - Phone:209-912-9021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician