Healthcare Provider Details

I. General information

NPI: 1629365077
Provider Name (Legal Business Name): MRS. ADRIENNE M. LEGUIZAMO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14515 HAMLIN ST
VAN NUYS CA
91411-1608
US

IV. Provider business mailing address

14515 HAMLIN ST
VAN NUYS CA
91411-1608
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number66217
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: