Basic Information
| Provider Information | |||||||||
| NPI: | 1447388434 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOCIAL MODEL RECOVERY SYSTEMS, INC. | ||||||||
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| OtherOrganizationName: | PASADENA COUNCIL ON ALCOHOLISM AND DRUG DEPENDENCE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 223 E ROWLAND ST | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917233147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263323145 | ||||||||
| FaxNumber: | 6269744164 | ||||||||
| Practice Location | |||||||||
| Address1: | 1245 E WALNUT ST | ||||||||
| Address2: | SUITE 101,103,107,109,115,117,118 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911061878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267959127 | ||||||||
| FaxNumber: | 6267950979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2007 | ||||||||
| LastUpdateDate: | 02/01/2017 | ||||||||
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| AuthorizedOfficialLastName: | DADES | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6263323145 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MA,MFT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 01735308 | 05 | CA | MEDICAID |