Healthcare Provider Details

I. General information

NPI: 1053570671
Provider Name (Legal Business Name): JOHN WILLIAMSON BEATTY, III LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 W VICTORIA ST
GARDENA CA
90248-3523
US

IV. Provider business mailing address

12105 STAMY RD
LA MIRADA CA
90638-1411
US

V. Phone/Fax

Practice location:
  • Phone: 310-715-2020
  • Fax:
Mailing address:
  • Phone: 562-947-4067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 5337
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: