Basic Information
| Provider Information | |||||||||
| NPI: | 1619308491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AKINS | ||||||||
| FirstName: | CONRAD | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, MSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AKINS-JOHNSON | ||||||||
| OtherFirstName: | CONRAD | ||||||||
| OtherMiddleName: | PAUL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW, MSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2085 RUSTIN AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925072498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519557320 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 24275 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925627285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516775599 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2013 | ||||||||
| LastUpdateDate: | 04/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 100879 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.