Healthcare Provider Details

I. General information

NPI: 1386339042
Provider Name (Legal Business Name): JESSE ERIN SEIFRIDSBERGER RADT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 04/10/2023
Certification Date: 04/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14515 HAMLIN ST
VAN NUYS CA
91411-1686
US

IV. Provider business mailing address

987 N SUMMIT AVE
PASADENA CA
91103-2618
US

V. Phone/Fax

Practice location:
  • Phone: 818-285-1900
  • Fax:
Mailing address:
  • Phone: 626-421-1074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1386170420
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: