Basic Information
| Provider Information | |||||||||
| NPI: | 1477753556 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UCLA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SEMEL INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 760 WESTWOOD PLZ | ||||||||
| Address2: | SUITE C8-222 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900245055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108250018 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 760 WESTWOOD PLZ | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900245055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108250018 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2007 | ||||||||
| LastUpdateDate: | 07/19/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | AMAYA | ||||||||
| AuthorizedOfficialFirstName: | KARINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | RESIDENCY COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 3108250018 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | A99803 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.