MEDICARE: KELLY DANIELLE FRIDAY CATC; 112519

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	CATC 112519	CA

General Provider Information

NPI Number	:	1790136364
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY DANIELLE FRIDAY CATC; 112519

Provider Business Mailing Address
First Line	:	1729 S MEYLER ST
Second Line	:	APT 1
City	:	SAN PEDRO
State	:	CA
Zip	:	90731-4649
Country	:	US
Telephone Number	:	310-831-9411
Fax Number	:	310-521-9241

Provider Business Practice Location Address
First Line	:	235 W 9TH ST
Second Line	:
City	:	SAN PEDRO
State	:	CA
Zip	:	90731-3711
Country	:	US
Telephone Number	:	310-521-9209
Fax Number	:	310-521-9241

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

Provider Enumeration Date	:	06/24/2016
Last Update Date	:	06/24/2016

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