Basic Information
| Provider Information | |||||||||
| NPI: | 1467583518 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIDI HIRSCH PSYCHIATRIC SERVICE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DIDI HIRSCH EXCELSIOR HOUSE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4760 SEPULVEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902304820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103906612 | ||||||||
| FaxNumber: | 3103985690 | ||||||||
| Practice Location | |||||||||
| Address1: | 1007 MYRTLE AVE | ||||||||
| Address2: | |||||||||
| City: | INGLEWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 903014009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104124191 | ||||||||
| FaxNumber: | 3104123942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 10/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | RUIZ | ||||||||
| AuthorizedOfficialFirstName: | DULCE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACTS & GRANTS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3107515442 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.