MEDICARE: LEVANTA COUNSELING SERVICESS LLC

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	320800000X	Mental Illness Community Based Residential Treatment Facility	197608981	CA

General Provider Information

NPI Number	:	1376917146
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEVANTA COUNSELING SERVICESS LLC

Provider Business Mailing Address
First Line	:	3013 ANNITA DR
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91206-1302
Country	:	US
Telephone Number	:	818-846-4469
Fax Number	:

Provider Business Practice Location Address
First Line	:	3013 ANNITA DR
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91206-1302
Country	:	US
Telephone Number	:	818-846-4469
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	TEODULO BONZON
Credential	:	LCSW
Telephone Number	:	818-846-4469

Provider Enumeration Date	:	11/17/2015
Last Update Date	:	11/17/2015

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