Provider Demographics
NPI:1568287050
Name:GERETSADIK GEREMIKAEL, RAHEL
Entity type:Individual
Prefix:
First Name:RAHEL
Middle Name:
Last Name:GERETSADIK GEREMIKAEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RAHEL
Other - Middle Name:
Other - Last Name:GEBRETSADIK GEBREMIKAEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 33568
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-3568
Mailing Address - Country:US
Mailing Address - Phone:855-223-7123
Mailing Address - Fax:
Practice Address - Street 1:1887 MONTEREY HWY STE 225
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-6192
Practice Address - Country:US
Practice Address - Phone:855-223-7123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-24-344470106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician