Organization · NPI-2

11821 Foothill Blvd

Counselor, Addiction (Substance Use Disorder) · Los Angeles, CA

NPI number1164767356
StatusActive
Last updated in NPPESNov 29, 2012

Details

NPI
1164767356
Entity type
Organization (NPI-2)
Legal business name
11821 Foothill Blvd
Organization subpart
No
Enumeration date
Nov 29, 2012
Last updated
Nov 29, 2012

Taxonomy and licenses

Taxonomy codeDescriptionLicenseStatePrimary
101YA0400X Counselor, Addiction (Substance Use Disorder)––Yes

Practice location

5436 S. Broadway
Los Angeles, CA 90037

Phone 818-694-7206

Mailing address

11821 Foothill Blvd # K35
Lake View Terrace, CA 91342-7200

Phone 818-694-7206

Authorized official

Derrick Bradley Fortune
Counselor
8186947206

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