Basic Information
Provider Information | |||||||||
NPI: | 1558911164 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SANTAMARIA | ||||||||
FirstName: | PATRICIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 323 N PRAIRIE AVE | ||||||||
Address2: |   | ||||||||
City: | INGLEWOOD | ||||||||
State: | CA | ||||||||
PostalCode: | 903014502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3108462100 | ||||||||
FaxNumber: | 3106777205 | ||||||||
Practice Location | |||||||||
Address1: | 4760 SEPULVEDA BLVD | ||||||||
Address2: |   | ||||||||
City: | CULVER CITY | ||||||||
State: | CA | ||||||||
PostalCode: | 902304820 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3103906612 | ||||||||
FaxNumber: | 3103985690 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/16/2019 | ||||||||
LastUpdateDate: | 03/04/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 02/09/2021 | ||||||||
NPIReactivationDate: | 02/26/2021 | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/04/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 101YM0800X | 98377 | CA | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.