Provider Demographics
NPI:1639403983
Name:DURHAM, ANTHONY JASON
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JASON
Last Name:DURHAM
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 1:3031 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-3033
Mailing Address - Country:US
Mailing Address - Phone:323-373-2400
Mailing Address - Fax:
Practice Address - Street 1:5054 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-2946
Practice Address - Country:US
Practice Address - Phone:323-373-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-18
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31881101YM0800X
CA654411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA65441OtherLCSW