Basic Information
Provider Information | |||||||||
NPI: | 1649843137 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAMPSHIRE | ||||||||
FirstName: | JUSTIN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RAD-T | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7231 HIDALGO ST | ||||||||
Address2: |   | ||||||||
City: | BUENA PARK | ||||||||
State: | CA | ||||||||
PostalCode: | 906212709 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7148184468 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1207 E FRUIT ST | ||||||||
Address2: |   | ||||||||
City: | SANTA ANA | ||||||||
State: | CA | ||||||||
PostalCode: | 927014296 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9099539373 | ||||||||
FaxNumber: | 7149537573 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/21/2021 | ||||||||
LastUpdateDate: | 07/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | R1436280721 | CA | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | 111 | 05 | CA |   | MEDICAID |