Healthcare Provider Details

I. General information

NPI: 1457060394
Provider Name (Legal Business Name): GRIFFIN MITTLEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2022
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 PICO BLVD
SANTA MONICA CA
90405-1326
US

IV. Provider business mailing address

2644 30TH ST STE 100
SANTA MONICA CA
90405-3051
US

V. Phone/Fax

Practice location:
  • Phone: 310-314-6200
  • Fax: 310-399-3675
Mailing address:
  • Phone: 310-314-6200
  • Fax: 310-450-2024

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: