Healthcare Provider Details

I. General information

NPI: 1861948705
Provider Name (Legal Business Name): COMMONWEALTH GLOBAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22231 MULHOLLAND HWY STE 211
CALABASAS CA
91302-5179
US

IV. Provider business mailing address

22231 MULHOLLAND HWY STE 211
CALABASAS CA
91302-5179
US

V. Phone/Fax

Practice location:
  • Phone: 818-651-4594
  • Fax:
Mailing address:
  • Phone: 818-651-4594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number190809AN
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number190808AN
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number190809AN
License Number State

VIII. Authorized Official

Name: KIRSTEN AMANDA WALLACE
Title or Position: CHIEF EXECUTIVE OFFICE
Credential: CEO
Phone: 818-651-4594