Healthcare Provider Details

I. General information

NPI: 1295443687
Provider Name (Legal Business Name): THOMAS ERNEST ROIDE II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 12/03/2022
Certification Date: 11/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4443 AMBROSE AVE
LOS ANGELES CA
90027-2114
US

IV. Provider business mailing address

PO BOX 29187
LOS ANGELES CA
90029-0187
US

V. Phone/Fax

Practice location:
  • Phone: 818-839-0759
  • Fax:
Mailing address:
  • Phone: 818-839-0759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: