Provider Demographics
NPI:1528400462
Name:ISLAM, RONNIE
Entity Type:Individual
Prefix:
First Name:RONNIE
Middle Name:
Last Name:ISLAM
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 1:3209 N ALAMEDA ST STE C
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90222-1454
Mailing Address - Country:US
Mailing Address - Phone:310-537-2273
Mailing Address - Fax:
Practice Address - Street 1:3209 N ALAMEDA ST STE C
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90222-1454
Practice Address - Country:US
Practice Address - Phone:310-537-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARI-I1207061659101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)