Healthcare Provider Details

I. General information

NPI: 1598110645
Provider Name (Legal Business Name): MR. AGUSTIN RANGEL JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2016
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 HAMPTON DR
VENICE CA
90291
US

IV. Provider business mailing address

9240 ELM VISTA DR APT A6
DOWNEY CA
90242-5320
US

V. Phone/Fax

Practice location:
  • Phone: 310-396-6468
  • Fax:
Mailing address:
  • Phone: 323-490-5546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW68759
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW68759
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: