Healthcare Provider Details

I. General information

NPI: 1396361069
Provider Name (Legal Business Name): GAGE FORTNEY-HENRIQUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2020
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3031 BEVERLY BLVD
LOS ANGELES CA
90057-1013
US

IV. Provider business mailing address

3031 BEVERLY BLVD
LOS ANGELES CA
90057-1013
US

V. Phone/Fax

Practice location:
  • Phone: 323-644-9380
  • Fax:
Mailing address:
  • Phone: 323-644-9380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-73974
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: