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General NPI Number Information
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NPI Number | 1164767356
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Entity Type | Organization
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Legal Business Name | 11821 FOOTHILL BLVD
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Dates
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Enumeration Date | 11/29/2012
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Last Update Date | 11/29/2012
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Provider Practice Location Address
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Address Line | 5436 S. BROADWAY
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City | LOS ANGELES
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State | CA
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Zip | 90037
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Country | US
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Telephone | 818-694-7206
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Fax |
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Provider Business Mailing Address
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Address Line | 11821 FOOTHILL BLVD # K35
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City | LAKE VIEW TERRACE
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State | CA
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Zip | 91342-7200
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Country | US
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Telephone | 818-694-7206
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Fax |
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Authorized Official
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Title or Position | COUNSELOR
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Name | MR. DERRICK BRADLEY FORTUNE
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Credential | BSHS
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Telephone | 818-694-7206
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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