Healthcare Provider Details

I. General information

NPI: 1356500920
Provider Name (Legal Business Name): SAMUEL ERIC FRASER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2008
Last Update Date: 06/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7136 HASKELL AVE SUITE 201
VAN NUYS CA
91406-4112
US

IV. Provider business mailing address

7136 HASKELL AVE SUITE 201
VAN NUYS CA
91406-4112
US

V. Phone/Fax

Practice location:
  • Phone: 626-644-4746
  • Fax: 818-888-7850
Mailing address:
  • Phone: 626-644-4746
  • Fax: 818-888-7850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberMFC23931
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMFC23931
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: