Provider Demographics
NPI:1356635700
Name:TADEVOSYAN, ALEN (RAS)
Entity Type:Individual
Prefix:
First Name:ALEN
Middle Name:
Last Name:TADEVOSYAN
Suffix:
Gender:M
Credentials:RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 N LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504-2628
Mailing Address - Country:US
Mailing Address - Phone:818-929-5757
Mailing Address - Fax:
Practice Address - Street 1:1020 N HOLLYWOOD WAY STE 13
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-2525
Practice Address - Country:US
Practice Address - Phone:818-929-5757
Practice Address - Fax:818-929-5757
Is Sole Proprietor?:No
Enumeration Date:2011-06-02
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAT1004070820101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)