Basic Information
| Provider Information | |||||||||
| NPI: | 1578690574 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STRAIGHT TALK CLINIC, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | STRAIGHT TALK CLINIC, INC. | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3785 S. PLAZA DRIVE | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148282000 | ||||||||
| FaxNumber: | 7148282396 | ||||||||
| Practice Location | |||||||||
| Address1: | 3785 S. PLAZA DRIVE | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148282000 | ||||||||
| FaxNumber: | 7148282396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 07/25/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCHROTH | ||||||||
| AuthorizedOfficialFirstName: | JANINE | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6572167751 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PH.D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | ZZZ41951Z | 01 | CA | BLUE SHIELD OF CA | OTHER |