Provider Demographics
NPI:1730753922
Name:FLANIGAN, NAZIEM DALTON
Entity type:Individual
Prefix:
First Name:NAZIEM
Middle Name:DALTON
Last Name:FLANIGAN
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 1:4450 W CENTURY BLVD
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90304-1504
Mailing Address - Country:US
Mailing Address - Phone:310-671-9294
Mailing Address - Fax:
Practice Address - Street 1:4450 W CENTURY BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90304-1504
Practice Address - Country:US
Practice Address - Phone:310-671-9294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1401370820101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF4605487OtherSTATE ID