Provider Demographics
NPI:1740426246
Name:VANDERGRIFT, ANNIE CELICE
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:CELICE
Last Name:VANDERGRIFT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:566 S SAN PEDRO ST # 447
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-2102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22030 SHERMAN WAY STE 115
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-1889
Practice Address - Country:US
Practice Address - Phone:818-340-0230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-05
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)