Basic Information
| Provider Information | |||||||||
| NPI: | 1871842237 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURTON | ||||||||
| FirstName: | DERRICK | ||||||||
| MiddleName: | KEITH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1264 W 81ST ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900442338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149067730 | ||||||||
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| Practice Location | |||||||||
| Address1: | 66 HURLBUT ST | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911054025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262545000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2012 | ||||||||
| LastUpdateDate: | 08/31/2012 | ||||||||
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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 | 101YA0400X | B1003311134 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | CATUS1-1362-010914S | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.