Healthcare Provider Details

I. General information

NPI: 1851424345
Provider Name (Legal Business Name): MICHAEL UDO D'AGOSTIN PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18646 OXNARD ST
TARZANA CA
91356-1411
US

IV. Provider business mailing address

13244 CUMPSTON ST
SHERMAN OAKS CA
91401-6008
US

V. Phone/Fax

Practice location:
  • Phone: 818-654-3845
  • Fax: 818-345-6402
Mailing address:
  • Phone: 818-997-8039
  • Fax: 818-376-1077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberA3555189
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY24187
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: