Healthcare Provider Details

I. General information

NPI: 1881745966
Provider Name (Legal Business Name): BIANCA M DAALDER MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1531 PURDUE AVE
WEST LOS ANGELES CA
90025-3104
US

IV. Provider business mailing address

1531 PURDUE AVE
WEST LOS ANGELES CA
90025-3104
US

V. Phone/Fax

Practice location:
  • Phone: 310-575-4503
  • Fax: 323-851-9926
Mailing address:
  • Phone: 310-575-4503
  • Fax: 323-851-9926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number36182
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: