Basic Information
| Provider Information | |||||||||
| NPI: | 1700116209 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HELPING KIDS TO RECOVER, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CENTINNIAL HIGH SCHOOL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 637 E. ALBERTONI ST. | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | CARSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102170616 | ||||||||
| FaxNumber: | 3102170545 | ||||||||
| Practice Location | |||||||||
| Address1: | 2606 N CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | COMPTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902221640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102170616 | ||||||||
| FaxNumber: | 3102170545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2010 | ||||||||
| LastUpdateDate: | 01/05/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOYD | ||||||||
| AuthorizedOfficialFirstName: | CHYNETHIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3102170616 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HELPING KIDS TO RECOVER, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.B.A.,RAS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X | Y | Agencies | Early Intervention Provider Agency |
ID Information
| ID | Type | State | Issuer | Description | 197247 | 05 | CA | MEDICAID |