Basic Information
| Provider Information | |||||||||
| NPI: | 1124306386 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOCIAL MODEL RECOVERY SYSTEMS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 223 E ROWLAND ST | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917233147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263323145 | ||||||||
| FaxNumber: | 6269744164 | ||||||||
| Practice Location | |||||||||
| Address1: | 453 S INDIANA ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900633908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232667725 | ||||||||
| FaxNumber: | 3232667742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2011 | ||||||||
| LastUpdateDate: | 10/07/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DADES | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6263323145 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOCIAL MODEL RECOVERY SYSTEMS, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MA. MFT. | ||||||||
| NPICertificationDate: | 10/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 190035CN | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.