Healthcare Provider Details

I. General information

NPI: 1255671327
Provider Name (Legal Business Name): ERIC DEREZA L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2013
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S VERMONT AVE FL 10
LOS ANGELES CA
90020-1912
US

IV. Provider business mailing address

550 S VERMONT AVE FL 10
LOS ANGELES CA
90020-1912
US

V. Phone/Fax

Practice location:
  • Phone: 213-760-1317
  • Fax: 213-996-1338
Mailing address:
  • Phone: 213-760-1317
  • Fax: 213-996-1338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number88623
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: