Healthcare Provider Details

I. General information

NPI: 1689422677
Provider Name (Legal Business Name): ELY COLE RAITT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2024
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3619 N MISSION RD
LINCOLN HEIGHTS CA
90031-3136
US

IV. Provider business mailing address

3619 N MISSION RD
LINCOLN HEIGHTS CA
90031-3136
US

V. Phone/Fax

Practice location:
  • Phone: 213-721-0010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberR1508070523
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: