Healthcare Provider Details

I. General information

NPI: 1053178228
Provider Name (Legal Business Name): RHONDA RENA HUMPHREY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 12/29/2024
Certification Date: 12/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 E FRUIT ST
SANTA ANA CA
92701-4206
US

IV. Provider business mailing address

1520 E 2ND ST APT 104
LONG BEACH CA
90802-5943
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-9373
  • Fax:
Mailing address:
  • Phone: 562-454-3298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSUDRC-18832
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: