Healthcare Provider Details

I. General information

NPI: 1134691538
Provider Name (Legal Business Name): ALDEN LOUGEE CMT, NMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2018
Last Update Date: 12/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14641 WYANDOTTE ST
VAN NUYS CA
91405-1933
US

IV. Provider business mailing address

14641 WYANDOTTE ST
VAN NUYS CA
91405-1933
US

V. Phone/Fax

Practice location:
  • Phone: 747-254-9559
  • Fax:
Mailing address:
  • Phone: 747-254-9559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number75430
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number76430
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: