Healthcare Provider Details

I. General information

NPI: 1528611886
Provider Name (Legal Business Name): HARLEY POTTS RADT-I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 S WESTLAKE AVE
LOS ANGELES CA
90057-2906
US

IV. Provider business mailing address

360 S WESTLAKE AVE
LOS ANGELES CA
90057-2906
US

V. Phone/Fax

Practice location:
  • Phone: 213-483-9202
  • Fax:
Mailing address:
  • Phone: 213-483-9202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRADT-I
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: