Healthcare Provider Details

I. General information

NPI: 1659762805
Provider Name (Legal Business Name): DALLAS DANIEL DUCHNICK BS BEHAVIORAL HEALTH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29201 HEATHERCLIFF RD #149
MALIBU CA
90265-4146
US

IV. Provider business mailing address

29201 HEATHERCLIFF RD #149
MALIBU CA
90265-4146
US

V. Phone/Fax

Practice location:
  • Phone: 888-456-2528
  • Fax:
Mailing address:
  • Phone: 888-456-2528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: