Provider Demographics
NPI:1407538390
Name:CERVANTES, PHILLIP
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:
Last Name:CERVANTES
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 1:5233 E BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-2020
Mailing Address - Country:US
Mailing Address - Phone:323-724-6911
Mailing Address - Fax:
Practice Address - Street 1:225 N MARIPOSA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-4509
Practice Address - Country:US
Practice Address - Phone:213-736-5441
Practice Address - Fax:213-736-5582
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1509740623101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)