Basic Information
| Provider Information | |||||||||
| NPI: | 1790162113 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREEDMAN | ||||||||
| FirstName: | JODI | ||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | STILLMAN | ||||||||
| OtherFirstName: | JODI | ||||||||
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| OtherCredential: | MFT TRAINEE | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 22110 ROSCOE BLVD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | CANOGA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913043845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187138700 | ||||||||
| FaxNumber: | 8187138585 | ||||||||
| Practice Location | |||||||||
| Address1: | 22110 ROSCOE BLVD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | CANOGA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913043845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187138700 | ||||||||
| FaxNumber: | 8187138585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2015 | ||||||||
| LastUpdateDate: | 05/05/2015 | ||||||||
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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 | R361014 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.