Basic Information
| Provider Information | |||||||||
| NPI: | 1407819881 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CYS-405 W. 5TH ST. STE 590, SA 92701 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 W 5TH ST | ||||||||
| Address2: | STE 590 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927014519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148345015 | ||||||||
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| Practice Location | |||||||||
| Address1: | 405 W 5TH ST | ||||||||
| Address2: | STE 590 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927014519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148345015 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MALIJEN | ||||||||
| AuthorizedOfficialFirstName: | ANNETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MARRIAGE FAMILY THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 7149357538 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MFT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC 36570 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.