=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649165978
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASTLE MICHAEL BRUSA CADC-I
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2025
-----------------------------------------------------
Last Update Date | 06/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11150 W OLYMPIC BLVD STE 760
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90064-1855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-800-4067
-----------------------------------------------------
Fax | 310-894-5354
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5702 VANALDEN AVE
-----------------------------------------------------
City | TARZANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91356-1225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-800-4067
-----------------------------------------------------
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 | CI41480124
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------