Provider Demographics
NPI:1558185959
Name:CHAVEZ, JUAN P (SUDRC#15723)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:P
Last Name:CHAVEZ
Suffix:
Gender:M
Credentials:SUDRC#15723
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 LANFRANCO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-4413
Mailing Address - Country:US
Mailing Address - Phone:323-534-9422
Mailing Address - Fax:
Practice Address - Street 1:1701 ZONAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1065
Practice Address - Country:US
Practice Address - Phone:323-223-6298
Practice Address - Fax:323-223-6399
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15723101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)