Basic Information
| Provider Information | |||||||||
| NPI: | 1467797522 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILLER CHILDREN'S HOSPITAL CENTER | ||||||||
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| OtherOrganizationName: | LONG BEACH MEMORIAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2801 ATLANTIC AVE | ||||||||
| Address2: | MCH-LONG BEACH MEMORIAL MEDICAL CENTER | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908061701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629332000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2801 ATLANTIC AVE | ||||||||
| Address2: | MCH-LONG BEACH MEMORIAL MEDICAL CENTER | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908061701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629332000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2012 | ||||||||
| LastUpdateDate: | 09/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | SOFTLEY | ||||||||
| AuthorizedOfficialFirstName: | TEDDI | ||||||||
| AuthorizedOfficialMiddleName: | LYNNEA | ||||||||
| AuthorizedOfficialTitleorPosition: | LICENSED CLINICAL PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 5629338600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LONG BEACH MEMORIAL MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PH.D. | ||||||||
| NPICertificationDate: | 09/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 281PC2000X | PSY15718 | CA | N | Hospitals | Chronic Disease Hospital | Children | 282NC2000X | PSY15718 | CA | Y | Hospitals | General Acute Care Hospital | Children |
No ID Information.