Basic Information
| Provider Information | |||||||||
| NPI: | 1336571280 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROTOTYPES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2555 E COLORADO BLVD | ||||||||
| Address2: | STE.100 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911076622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6265772261 | ||||||||
| FaxNumber: | 6265772543 | ||||||||
| Practice Location | |||||||||
| Address1: | 2555 E COLORADO BLVD | ||||||||
| Address2: | STE.100 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911076622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6265772261 | ||||||||
| FaxNumber: | 6265772543 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2013 | ||||||||
| LastUpdateDate: | 08/02/2013 | ||||||||
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| AuthorizedOfficialLastName: | DOSS | ||||||||
| AuthorizedOfficialFirstName: | DORIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6265772261 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MFT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | LCS 28715 | CA | Y | Agencies | Community/Behavioral Health |
No ID Information.