Provider Demographics
NPI:1528616794
Name:RADWAN, ADAM ABRAHAM
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:ABRAHAM
Last Name:RADWAN
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 1:3850 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-1821
Mailing Address - Country:US
Mailing Address - Phone:323-596-2480
Mailing Address - Fax:
Practice Address - Street 1:3850 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-1821
Practice Address - Country:US
Practice Address - Phone:323-596-2480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-29
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 390200000X
CA97361101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program