Provider Demographics
NPI:1174294060
Name:FLANNERY, WILLIAM EDWARD (SUDCC)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:EDWARD
Last Name:FLANNERY
Suffix:
Gender:M
Credentials:SUDCC
Other - Prefix:MR
Other - First Name:WILLIAM
Other - Middle Name:E
Other - Last Name:FLANNERY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SUDCC
Mailing Address - Street 1:11975 TEXAS AVE APT 302
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-7705
Mailing Address - Country:US
Mailing Address - Phone:925-570-1446
Mailing Address - Fax:
Practice Address - Street 1:905 PICO BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-1326
Practice Address - Country:US
Practice Address - Phone:310-314-6200
Practice Address - Fax:310-450-2024
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11915101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)