Healthcare Provider Details

I. General information

NPI: 1821464462
Provider Name (Legal Business Name): LISHI LEO HUANG SUPPORT SPECIALIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2015
Last Update Date: 03/26/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2116 S CENTRAL AVE
LOS ANGELES CA
90011-1237
US

IV. Provider business mailing address

2116 S CENTRAL AVE
LOS ANGELES CA
90011-1237
US

V. Phone/Fax

Practice location:
  • Phone: 213-493-4664
  • Fax:
Mailing address:
  • Phone: 213-493-4664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1910559
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: