Healthcare Provider Details

I. General information

NPI: 1235041740
Provider Name (Legal Business Name): JOSE LUIS MALTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11726 LEMAY ST APT 15
NORTH HOLLYWOOD CA
91606-1639
US

IV. Provider business mailing address

11642 VICTORY BLVD # 146
NORTH HOLLYWOOD CA
91606-3514
US

V. Phone/Fax

Practice location:
  • Phone: 661-488-1694
  • Fax:
Mailing address:
  • Phone: 661-488-1694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number23811
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: