11821 Foothill Blvd

Primary specialty

Addiction (Substance Use Disorder) CounselorTaxonomy code 101YA0400X

Legal business name

11821 FOOTHILL BLVD

Practice address

5436 S. Broadway
Los Angeles, CA 90037

Phone

(818) 694-7206

NPI assigned

Nov 29, 2012

Last updated

Nov 29, 2012By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Derrick Bradley Fortune, BSHS

Title

Counselor

Phone

(818) 694-7206

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1354147200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1354147200000",
    "number": "1164767356",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11821 FOOTHILL BLVD # K35",
            "city": "LAKE VIEW TERRACE",
            "state": "CA",
            "postal_code": "913427200",
            "telephone_number": "818-694-7206"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5436 S. BROADWAY",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "90037",
            "telephone_number": "818-694-7206"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "11821 FOOTHILL BLVD",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-11-29",
        "last_updated": "2012-11-29",
        "status": "A",
        "authorized_official_last_name": "FORTUNE",
        "authorized_official_first_name": "DERRICK",
        "authorized_official_middle_name": "BRADLEY",
        "authorized_official_title_or_position": "COUNSELOR",
        "authorized_official_telephone_number": "818-694-7206",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "BSHS"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Addiction (Substance Use Disorder) Counselor in Los Angeles, CA
• Providers in Los Angeles, CA by specialty
• Addiction (Substance Use Disorder) Counselor in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 29, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.