Healthcare Provider Details

I. General information

NPI: 1528202207
Provider Name (Legal Business Name): PHILIP V SPRADLING MFT INTERN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 04/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2046 ALLEN AVE
ALTADENA CA
91001-3424
US

IV. Provider business mailing address

400 N OAKLAND AVE #206
PASADENA CA
91101-1444
US

V. Phone/Fax

Practice location:
  • Phone: 626-396-5920
  • Fax:
Mailing address:
  • Phone: 626-396-5920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number59828
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number59828
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: