Healthcare Provider Details

I. General information

NPI: 1326423518
Provider Name (Legal Business Name): MR. MATTHEW CONWAY BUMPASS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2015
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 BAUCHET ST.
LOS ANGELES CA
90012
US

IV. Provider business mailing address

450 BAUCHET ST
LOS ANGELES CA
90012-2907
US

V. Phone/Fax

Practice location:
  • Phone: 213-893-5091
  • Fax: 213-972-4012
Mailing address:
  • Phone: 213-893-5091
  • Fax: 213-972-4012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: