Basic Information
| Provider Information | |||||||||
| NPI: | 1710439492 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEDROZA | ||||||||
| FirstName: | CONRAD | ||||||||
| MiddleName: | RODNEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 E 4TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927053916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148248140 | ||||||||
| FaxNumber: | 7148248142 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 E 4TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148248140 | ||||||||
| FaxNumber: | 7148248142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2016 | ||||||||
| LastUpdateDate: | 07/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 302R00000X | CA | Y | Managed Care Organizations | Health Maintenance Organization |
ID Information
| ID | Type | State | Issuer | Description | C5104288 | 01 | CA | MENTAL HEALTH | OTHER |