Basic Information
| Provider Information | |||||||||
| NPI: | 1457809758 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALIFORNIA THERAPY CENTER AND PSYCHOLOGICAL SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 N PACIFIC AVE | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912023250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183965343 | ||||||||
| FaxNumber: | 8185613997 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 N PACIFIC AVE | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912023250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183965343 | ||||||||
| FaxNumber: | 8185613997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2016 | ||||||||
| LastUpdateDate: | 09/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | TAMASSIAN | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL PSYCHOLOGIST/ PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8183965345 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY19694 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 00CP196940 | 05 | CA | MEDICAID |