Basic Information
| Provider Information | |||||||||
| NPI: | 1811442585 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ENNACO | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1804 S 8TH ST | ||||||||
| Address2: | |||||||||
| City: | ALHAMBRA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 918033419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607975542 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18646 OXNARD ST | ||||||||
| Address2: | |||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913561411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189961051 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2016 | ||||||||
| LastUpdateDate: | 10/10/2019 | ||||||||
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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 | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 103T00000X | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.