Healthcare Provider Details

I. General information

NPI: 1295522001
Provider Name (Legal Business Name): WILL DESMIT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2025
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 N GARDNER ST
LOS ANGELES CA
90046-4102
US

IV. Provider business mailing address

1450 N GARDNER ST
LOS ANGELES CA
90046-4102
US

V. Phone/Fax

Practice location:
  • Phone: 617-320-6628
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberAPCC18657
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number25-141
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: