Basic Information
| Provider Information | |||||||||
| NPI: | 1215186556 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EBESUTANI | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | KIYOSHI | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 951563 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900951563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108253301 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 VETERAN AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900242704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108253301 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2008 | ||||||||
| LastUpdateDate: | 10/02/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | H00715964 | HI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.