Healthcare Provider Details

I. General information

NPI: 1598620064
Provider Name (Legal Business Name): DANIEL THOMAS ETEMADI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4853 JESSIE AVE APT 3
LA MESA CA
91942-8676
US

IV. Provider business mailing address

4853 JESSIE AVE APT 3
LA MESA CA
91942-8676
US

V. Phone/Fax

Practice location:
  • Phone: 619-536-9374
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: