Healthcare Provider Details

I. General information

NPI: 1215253224
Provider Name (Legal Business Name): MICHAEL MARSHALL WHITED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

954 N VERMONT AVE
LOS ANGELES CA
90029-3529
US

IV. Provider business mailing address

5650 JILLSON ST
COMMERCE CA
90040-1482
US

V. Phone/Fax

Practice location:
  • Phone: 562-867-7999
  • Fax:
Mailing address:
  • Phone: 562-867-7999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95005776
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number757022-1
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95040852
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: