Provider Demographics
NPI:1154023497
Name:INGERSOLL, DANIEL JL (SUDCC)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JL
Last Name:INGERSOLL
Suffix:
Gender:M
Credentials:SUDCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 491542
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-9542
Mailing Address - Country:US
Mailing Address - Phone:862-596-3875
Mailing Address - Fax:
Practice Address - Street 1:2201 PARNELL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-2004
Practice Address - Country:US
Practice Address - Phone:310-560-3794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2024-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA11533101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor