Provider Demographics
NPI:1568124535
Name:ANDERSON, DANIELLE (RADT)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1739 AXENTY WAY
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-2811
Mailing Address - Country:US
Mailing Address - Phone:310-487-3059
Mailing Address - Fax:
Practice Address - Street 1:15519 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-4525
Practice Address - Country:US
Practice Address - Phone:310-679-9031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1455100122101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)