Basic Information
| Provider Information | |||||||||
| NPI: | 1740573690 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTER SEALS SOUTHERN CALIFORNIA, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 E EDINGER AVE | ||||||||
| Address2: | STE 190 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927054754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148341111 | ||||||||
| FaxNumber: | 7148341128 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W CENTRAL AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | BREA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928213027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148341111 | ||||||||
| FaxNumber: | 7148341128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2011 | ||||||||
| LastUpdateDate: | 05/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | BERGLUND | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7148341111 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.