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General NPI Number Information
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NPI Number | 1871842237
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Entity Type | Individual
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Provider Name | DERRICK KEITH BURTON
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Gender | Male
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Dates
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Enumeration Date | 08/31/2012
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Last Update Date | 08/31/2012
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Provider Practice Location Address
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Address Line | 66 HURLBUT ST
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City | PASADENA
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State | CA
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Zip | 91105-4025
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Country | US
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Telephone | 626-254-5000
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Fax |
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Provider Business Mailing Address
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Address Line | 1264 W 81ST ST
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City | LOS ANGELES
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State | CA
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Zip | 90044-2338
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Country | US
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Telephone | 714-906-7730
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | B1003311134
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CATUS1-1362-010914S
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License Number State | CA
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