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General NPI Number Information
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NPI Number | 1588341689
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Entity Type | Organization
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Legal Business Name | PSYCHEDELIC MEDICAL ASSOCIATES PC
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Dates
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Enumeration Date | 06/29/2023
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Last Update Date | 06/29/2023
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Provider Practice Location Address
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Address Line | 1247 7TH ST STE 300
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City | SANTA MONICA
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State | CA
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Zip | 90401-1644
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Country | US
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Telephone | 310-393-7129
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Fax | 310-564-7839
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Provider Business Mailing Address
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Address Line | 1247 7TH ST STE 300
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City | SANTA MONICA
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State | CA
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Zip | 90401-1644
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Country | US
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Telephone | 310-393-7129
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Fax | 310-564-7839
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. KEITH HEINZERLING
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Credential | MD
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Telephone | 310-393-7129
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207RA0401X
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Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
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License Number |
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License Number State |
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