Healthcare Provider Details

I. General information

NPI: 1033024716
Provider Name (Legal Business Name): TY DAVID STOCKMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 CRENSHAW BLVD STE 215
LOS ANGELES CA
90043-1200
US

IV. Provider business mailing address

11836 N HILLSBOROUGH LN
PORTER RANCH CA
91326-4980
US

V. Phone/Fax

Practice location:
  • Phone: 323-291-7100
  • Fax:
Mailing address:
  • Phone: 323-291-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number106S00000X-
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: