Provider Demographics
NPI:1215186556
Name:EBESUTANI, CHAD KIYOSHI
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:KIYOSHI
Last Name:EBESUTANI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 951563
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-1563
Mailing Address - Country:US
Mailing Address - Phone:310-825-3301
Mailing Address - Fax:
Practice Address - Street 1:1000 VETERAN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-2704
Practice Address - Country:US
Practice Address - Phone:310-825-3301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-11
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIH00715964103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical