Provider Demographics
NPI:1578937637
Name:PROFOUND TREATMENT
Entity Type:Organization
Organization Name:PROFOUND TREATMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:MR
Authorized Official - First Name:TREVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:CAADC
Authorized Official - Phone:310-600-2395
Mailing Address - Street 1:22717 LEADWELL ST
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-2106
Mailing Address - Country:US
Mailing Address - Phone:310-600-2395
Mailing Address - Fax:
Practice Address - Street 1:1990 WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-4650
Practice Address - Country:US
Practice Address - Phone:310-600-2395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-30
Last Update Date:2021-05-18
Deactivation Date:2021-03-09
Deactivation Code:
Reactivation Date:2021-05-18
Provider Licenses
StateLicense IDTaxonomies
CA102556101YA0400X
CA36882106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty