Healthcare Provider Details

I. General information

NPI: 1780077859
Provider Name (Legal Business Name): KIRK WILLIAMS CAS-AOD SPECIALIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2015
Last Update Date: 03/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3756 SANTA ROSALIA DR STE 417
LOS ANGELES CA
90008-3614
US

IV. Provider business mailing address

3756 SANTA ROSALIA DR STE 417
LOS ANGELES CA
90008-3614
US

V. Phone/Fax

Practice location:
  • Phone: 323-295-1136
  • Fax: 323-295-1071
Mailing address:
  • Phone: 323-295-1136
  • Fax: 323-295-1071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: