Provider Demographics
NPI:1164244174
Name:DATTER, JULIE NICOLE (RADT)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:NICOLE
Last Name:DATTER
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:JEWELS
Other - Middle Name:NICOLE
Other - Last Name:DATTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RADT
Mailing Address - Street 1:2460 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MORRO BAY
Mailing Address - State:CA
Mailing Address - Zip Code:93442-1552
Mailing Address - Country:US
Mailing Address - Phone:805-235-8098
Mailing Address - Fax:
Practice Address - Street 1:2460 MAIN ST
Practice Address - Street 2:
Practice Address - City:MORRO BAY
Practice Address - State:CA
Practice Address - Zip Code:93442-1552
Practice Address - Country:US
Practice Address - Phone:805-772-2212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1505660523101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty