Basic Information
| Provider Information | |||||||||
| NPI: | 1770975914 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SO. CAL. CHILD THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6320 CANOGA AVE | ||||||||
| Address2: | 15TH FLOOR | ||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913672526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188040322 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6320 CANOGA AVE | ||||||||
| Address2: | 15TH FLOOR | ||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913672526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188040322 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2015 | ||||||||
| LastUpdateDate: | 02/25/2015 | ||||||||
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| AuthorizedOfficialLastName: | JAKUBANIS | ||||||||
| AuthorizedOfficialFirstName: | BETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8188040322 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041S0200X | LCS 28234 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | School | 1041C0700X | LCS 28234 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1700079191 | 01 | INDIVIDUAL NPI NUMBER | OTHER |