Provider Demographics
NPI:1689259947
Name:ADOLPHUS, DOREAN
Entity Type:Individual
Prefix:
First Name:DOREAN
Middle Name:
Last Name:ADOLPHUS
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 1:140 W 124TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90061-1721
Mailing Address - Country:US
Mailing Address - Phone:323-996-6436
Mailing Address - Fax:
Practice Address - Street 1:4952 WARNER AVE STE 300
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-5506
Practice Address - Country:US
Practice Address - Phone:877-910-6538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABACB609491106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician