Basic Information
Provider Information | |||||||||
NPI: | 1255635827 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SPIRITT FAMILY SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2000 TYLER AVE | ||||||||
Address2: |   | ||||||||
City: | SOUTH EL MONTE | ||||||||
State: | CA | ||||||||
PostalCode: | 917333543 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6264421400 | ||||||||
FaxNumber: | 6264421144 | ||||||||
Practice Location | |||||||||
Address1: | 2000 TYLER AVE | ||||||||
Address2: |   | ||||||||
City: | SOUTH EL MONTE | ||||||||
State: | CA | ||||||||
PostalCode: | 917333543 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6264421400 | ||||||||
FaxNumber: | 6264421144 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2010 | ||||||||
LastUpdateDate: | 01/14/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCHIADA | ||||||||
AuthorizedOfficialFirstName: | DUSTIN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 6264421400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LMFT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 95-2852686 | 01 | CA | MEDI-CAL | OTHER |