MEDICARE: DANIEL JL INGERSOLL SUDCC-II CS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	11533	CA

General Provider Information

NPI Number	:	1154023497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL JL INGERSOLL SUDCC-II CS

Provider Business Mailing Address
First Line	:	PO BOX 491542
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-9542
Country	:	US
Telephone Number	:	862-596-3875
Fax Number	:

Provider Business Practice Location Address
First Line	:	2201 PARNELL AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-2004
Country	:	US
Telephone Number	:	310-560-3794
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2023
Last Update Date	:	06/27/2025

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