Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker | CA | |
N | 225400000X | Rehabilitation Practitioner |
NPI | 1033577531 |
---|---|
Provider Name | Mr. Justin Colwell |
First Address | Inglewood, CA 90302-1131 |
Second Address | Inglewood, CA 90302 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/01/2016 |
Last Update Date | 20/08/2018 |