Basic Information
| Provider Information | |||||||||
| NPI: | 1568891612 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROTOTYPES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2555 E COLORADO BLVD | ||||||||
| Address2: | SUITE 100-101 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911076622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6265772261 | ||||||||
| FaxNumber: | 6265772543 | ||||||||
| Practice Location | |||||||||
| Address1: | 2555 E COLORADO BLVD | ||||||||
| Address2: | SUITE 100-101 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911076622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6265772261 | ||||||||
| FaxNumber: | 6265772543 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2013 | ||||||||
| LastUpdateDate: | 11/08/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEDINA SNYDER | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SUPERVISOR II | ||||||||
| AuthorizedOfficialTelephone: | 6265772261 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | Y | Managed Care Organizations | Exclusive Provider Organization |
No ID Information.