Healthcare Provider Details

I. General information

NPI: 1841324407
Provider Name (Legal Business Name): MR. DEANE AHMED HENRYSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10155 COLIMA RD
WHITTIER CA
90603-2063
US

IV. Provider business mailing address

22879 HILTON HEAD DR
DIAMOND BAR CA
91765-4411
US

V. Phone/Fax

Practice location:
  • Phone: 562-692-0383
  • Fax:
Mailing address:
  • Phone: 909-861-0394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16128
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: