Healthcare Provider Details

I. General information

NPI: 1508519174
Provider Name (Legal Business Name): DESIREE MICHELLE ROSE RADT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2022
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7232 CANBY AVE STE 456
RESEDA CA
91335-3006
US

IV. Provider business mailing address

7232 CANBY AVE STE 456
RESEDA CA
91335-3006
US

V. Phone/Fax

Practice location:
  • Phone: 818-705-5561
  • Fax: 818-705-8248
Mailing address:
  • Phone: 818-705-5561
  • Fax: 818-705-8248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: