Healthcare Provider Details

I. General information

NPI: 1588341689
Provider Name (Legal Business Name): PSYCHEDELIC MEDICAL ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1247 7TH ST STE 300
SANTA MONICA CA
90401-1644
US

IV. Provider business mailing address

1247 7TH ST STE 300
SANTA MONICA CA
90401-1644
US

V. Phone/Fax

Practice location:
  • Phone: 310-393-7129
  • Fax: 310-564-7839
Mailing address:
  • Phone: 310-393-7129
  • Fax: 310-564-7839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KEITH HEINZERLING
Title or Position: DIRECTOR
Credential: MD
Phone: 310-393-7129