Basic Information
| Provider Information | |||||||||
| NPI: | 1417083049 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDRENS BUREAU OF SOUTHERN CALIFORNIA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHILDRENS BUREAU CARSON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 E CARSON PLAZA DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | CARSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907463228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105239500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 460 E CARSON PLAZA DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | CARSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907463228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105239500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 06/06/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | ALEX | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3239537350 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | CA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 7570A | 01 | CA | DMH REPORTING UNIT | OTHER | 00007570 | 05 | CA | MEDICAID | 00668 | 01 | CA | DMH LEGAL ENITITY NUMBER | OTHER |