Healthcare Provider Details

I. General information

NPI: 1538601828
Provider Name (Legal Business Name): STACEY URAUCHI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2016
Last Update Date: 11/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 AVILA ST STE 102
LOS ANGELES CA
90012-4287
US

IV. Provider business mailing address

900 AVILA ST STE 102
LOS ANGELES CA
90012-4287
US

V. Phone/Fax

Practice location:
  • Phone: 213-229-0985
  • Fax: 213-229-0986
Mailing address:
  • Phone: 213-229-0985
  • Fax: 213-229-0986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1235281016
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: