Basic Information
| Provider Information | |||||||||
| NPI: | 1275753394 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRICENO | ||||||||
| FirstName: | ANNETTE | ||||||||
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| Credential: | CAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9217 E OTTO STREET | ||||||||
| Address2: | |||||||||
| City: | DOWNEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629648751 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3125 E 7TH ST | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908044932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624397755 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1989 | 05 | CA | MEDICAID |