Basic Information
| Provider Information | |||||||||
| NPI: | 1821112947 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORTEZA | ||||||||
| FirstName: | HERMAN | ||||||||
| MiddleName: | MATA | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.S., MSW, ASW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4771 ROUND TOP DR | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900655237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103085222 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2550 E FOOTHILL BLVD FL 2 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911073406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267445230 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 11/10/2014 | ||||||||
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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 | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | 36663 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | 36663 | CA | N | Behavioral Health & Social Service Providers | Social Worker | 101YA0400X | 36663 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.