Healthcare Provider Details

I. General information

NPI: 1710677539
Provider Name (Legal Business Name): ADRIAAN J VAN ZYL AMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1576 MUNSON AVE
LOS ANGELES CA
90042-1627
US

IV. Provider business mailing address

2355 WESTWOOD BLVD STE 309
LOS ANGELES CA
90064-2109
US

V. Phone/Fax

Practice location:
  • Phone: 646-267-2496
  • Fax:
Mailing address:
  • Phone: 646-267-2496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number139409
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number139409
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number139409
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: