Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) |
NPI | 1003115437 |
---|---|
Provider Name | Mr. Ellison Mcqueen |
First Address | Long Beach, CA 90804-4708 |
Second Address | Long Beach, CA 90804-4708 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/03/2011 |
Last Update Date | 24/03/2011 |