Basic Information
| Provider Information | |||||||||
| NPI: | 1225332802 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHOENIX HOUSE ORANGE COUNTY, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CYS PHOENIX WRAPAROUND | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1615 E. 17TH ST | ||||||||
| Address2: | SUITE #100 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149554042 | ||||||||
| FaxNumber: | 7145417924 | ||||||||
| Practice Location | |||||||||
| Address1: | 1615 E. 17TH ST | ||||||||
| Address2: | SUITE #100 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149554042 | ||||||||
| FaxNumber: | 7145417924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2010 | ||||||||
| LastUpdateDate: | 03/20/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ABBASSI | ||||||||
| AuthorizedOfficialFirstName: | POURIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SEN. VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8186863000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.