Healthcare Provider Details

I. General information

NPI: 1467011130
Provider Name (Legal Business Name): KENNETH DSNIEL FREEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: KENNETH DANIEL FREEMAN

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 06/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 ATLANTIC AVE
LONG BEACH CA
90806-2708
US

IV. Provider business mailing address

2501 ATLANTIC AVE
LONG BEACH CA
90806-2708
US

V. Phone/Fax

Practice location:
  • Phone: 562-424-6105
  • Fax: 562-427-1678
Mailing address:
  • Phone: 562-424-6105
  • Fax: 562-427-1678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
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: