Healthcare Provider Details

I. General information

NPI: 1396140265
Provider Name (Legal Business Name): TIMOTHY JAMES HUTSON MCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 W 9TH ST SUITE 103
SAN PEDRO CA
90731-3158
US

IV. Provider business mailing address

1409 WHITE OAK CIR
OJAI CA
93023-1931
US

V. Phone/Fax

Practice location:
  • Phone: 310-938-4575
  • Fax:
Mailing address:
  • Phone: 310-940-0017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberH0906261427
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: