Provider Demographics
NPI:1619170388
Name:HARRAWAY, ALLAN EDWARD (AOD)
Entity Type:Individual
Prefix:MR
First Name:ALLAN
Middle Name:EDWARD
Last Name:HARRAWAY
Suffix:
Gender:M
Credentials:AOD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 W 22ND ST #207
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018
Mailing Address - Country:US
Mailing Address - Phone:323-302-2765
Mailing Address - Fax:
Practice Address - Street 1:614 W MANCHESTER BLVD STE 104
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1683
Practice Address - Country:US
Practice Address - Phone:310-412-0879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC30111214101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA743045262OtherTAX ID