Healthcare Provider Details

I. General information

NPI: 1790265296
Provider Name (Legal Business Name): AMY HEUANSAVATH RADT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N LA BREA AVE
INGLEWOOD CA
90302-3049
US

IV. Provider business mailing address

2900 CRENSHAW BLVD
LOS ANGELES CA
90016-4265
US

V. Phone/Fax

Practice location:
  • Phone: 323-294-4932
  • Fax:
Mailing address:
  • Phone: 323-293-6284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: