Provider Demographics
NPI:1700258829
Name:WISDOM TREATMENT, LLC
Entity Type:Organization
Organization Name:WISDOM TREATMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:BARSALOU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-489-4592
Mailing Address - Street 1:7361 TOPANGA CANYON BLVD
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-3387
Mailing Address - Country:US
Mailing Address - Phone:818-489-4592
Mailing Address - Fax:
Practice Address - Street 1:7361 TOPANGA CANYON BLVD
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-3387
Practice Address - Country:US
Practice Address - Phone:818-489-4592
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-28
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA190887APOtherCALIFORNIA CERTIFICATION