Healthcare Provider Details

I. General information

NPI: 1922648229
Provider Name (Legal Business Name): MR. SEBASTIAN ERDMAN-WATERHOUSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W BROADWAY STE 750
GLENDALE CA
91210-1215
US

IV. Provider business mailing address

100 W BROADWAY STE 750
GLENDALE CA
91210-1215
US

V. Phone/Fax

Practice location:
  • Phone: 323-419-4103
  • Fax: 323-419-5507
Mailing address:
  • Phone: 323-419-4103
  • Fax: 323-419-5507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: