Healthcare Provider Details

I. General information

NPI: 1558083725
Provider Name (Legal Business Name): ANTONIO CHARLES FIDLER-WOODARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4067 HARDWICK ST # 363
LAKEWOOD CA
90712-2350
US

IV. Provider business mailing address

4067 HARDWICK ST # 363
LAKEWOOD CA
90712-2350
US

V. Phone/Fax

Practice location:
  • Phone: 323-849-0220
  • Fax:
Mailing address:
  • Phone: 323-849-0220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number131056
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number107950
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: