Healthcare Provider Details

I. General information

NPI: 1235745639
Provider Name (Legal Business Name): RENE MONTIJO A067980426
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14530 SYLVAN ST
VAN NUYS CA
91411-2324
US

IV. Provider business mailing address

14530 SYLVAN ST
VAN NUYS CA
91411-2324
US

V. Phone/Fax

Practice location:
  • Phone: 323-222-1440
  • Fax:
Mailing address:
  • Phone: 323-222-1440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberA067980426
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: