Basic Information
| Provider Information | |||||||||
| NPI: | 1457895922 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SURJONO | ||||||||
| FirstName: | BAYLIE | ||||||||
| MiddleName: | M | ||||||||
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| OtherLastName: | ALLEN | ||||||||
| OtherFirstName: | BAYLIE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2859 E VALLEY BLVD APT 81 | ||||||||
| Address2: | |||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917923191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7202908637 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1000 GOODRICH BLVD | ||||||||
| Address2: | |||||||||
| City: | COMMERCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900225103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238329795 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2016 | ||||||||
| LastUpdateDate: | 12/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF94213 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.