Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | CA |
NPI | 1003408782 |
---|---|
Provider Name | Ricky Burnell |
First Address | Fullerton, CA 92832-2806 |
Second Address | Fullerton, CA 92832-2806 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/02/2021 |
Last Update Date | 04/02/2021 |