Basic Information
| Provider Information | |||||||||
| NPI: | 1376674986 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOWARD | ||||||||
| FirstName: | DWIGHT | ||||||||
| MiddleName: | DOUGLAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14128 CALVERT ST | ||||||||
| Address2: | APT.310 | ||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914013473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189010436 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14128 CALVERT ST | ||||||||
| Address2: | #310 | ||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914013473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189014836 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 12/20/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 7420 | 05 | CA | MEDICAID | 7068 | 05 | CA | MEDICAID |