Basic Information
| Provider Information | |||||||||
| NPI: | 1679129415 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TORRES | ||||||||
| FirstName: | SHAYDRA | ||||||||
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| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1132 W HARDING AVE | ||||||||
| Address2: | |||||||||
| City: | MONTEBELLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906404126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237971627 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3881 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900621105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232904340 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2019 | ||||||||
| LastUpdateDate: | 10/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.