=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326924283
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL ROBERT PETROSIAN RADT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2025
-----------------------------------------------------
Last Update Date | 08/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 616-620 S ATLANTIC BLVD.
-----------------------------------------------------
City | MONTEREY PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-427-1495
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3425 EMERALD ISLE DR
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91206-1117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-288-3799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | R1551220224
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------