Basic Information
| Provider Information | |||||||||
| NPI: | 1093102766 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S HOSPITAL OF ORANGE COUNTY | ||||||||
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| OtherOrganizationName: | CHOC DEPT OF PSYCHOLOGY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 W LA VETA AVE | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928684203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145098649 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1120 W LA VETA AVE | ||||||||
| Address2: | SUITE 470 | ||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928684231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145098481 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2015 | ||||||||
| LastUpdateDate: | 04/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | SCHILLER | ||||||||
| AuthorizedOfficialFirstName: | KERRI | ||||||||
| AuthorizedOfficialMiddleName: | RUPPERT | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7145098405 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHILDREN'S HOSPITAL OF ORANGE COUNTY | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.