Healthcare Provider Details

I. General information

NPI: 1912416785
Provider Name (Legal Business Name): DONALD LAND SUD COUNSELOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2017
Last Update Date: 09/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 W EL SEGUNDO BLVD
HAWTHORNE CA
90250-3317
US

IV. Provider business mailing address

2501 W EL SEGUNDO BLVD
HAWTHORNE CA
90250-3317
US

V. Phone/Fax

Practice location:
  • Phone: 323-754-2816
  • Fax: 323-754-2828
Mailing address:
  • Phone: 323-754-2816
  • Fax: 323-754-2828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12432-R
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: