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Organization
11821 FOOTHILL BLVD
Active
Organization
11821 FOOTHILL BLVD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DERRICK BRADLEY FORTUNE BSHS (COUNSELOR)
(818) 694-7206
Entity
Organization
Contact information
Practice address
5436 S. BROADWAY, LOS ANGELES, CA 90037
(818) 694-7206
Mailing address
11821 FOOTHILL BLVD # K35, LAKE VIEW TERRACE, CA 91342-7200
(818) 694-7206
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
—
Other
Enumeration date
11/29/2012
Last updated
11/29/2012
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