Provider Demographics
NPI:1134878150
Name:BALTAZAR, JUAN JOSE
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:JOSE
Last Name:BALTAZAR
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 1:3510 BLANCHARD ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90063-3804
Mailing Address - Country:US
Mailing Address - Phone:213-572-8407
Mailing Address - Fax:
Practice Address - Street 1:305 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1709
Practice Address - Country:US
Practice Address - Phone:213-372-5233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1367801019101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)