Basic Information
| Provider Information | |||||||||
| NPI: | 1245360130 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEHAVIORAL HEALTH SERVICES INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PACIFICA HOUSE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 15519 CRENSHAW BLVD | ||||||||
| Address2: | |||||||||
| City: | GARDENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902494525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106799126 | ||||||||
| FaxNumber: | 3106792920 | ||||||||
| Practice Location | |||||||||
| Address1: | 2501 W EL SEGUNDO BLVD | ||||||||
| Address2: | |||||||||
| City: | HAWTHORNE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902503317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237542816 | ||||||||
| FaxNumber: | 3237542828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CANNON | ||||||||
| AuthorizedOfficialFirstName: | TERI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3106799126 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 190007GN | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 190007GN | 01 | CA | DRUG AND ALCOHOL LICENSE | OTHER |