Healthcare Provider Details

I. General information

NPI: 1437540531
Provider Name (Legal Business Name): KEVIN YZAGUIRRE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14515 HAMLIN ST STE 100
VAN NUYS CA
91411-1694
US

IV. Provider business mailing address

14515 HAMLIN ST STE 100
VAN NUYS CA
91411-1694
US

V. Phone/Fax

Practice location:
  • Phone: 818-285-1900
  • Fax: 818-285-1906
Mailing address:
  • Phone: 818-285-1900
  • Fax: 818-285-1906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number143365
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number139894
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: