Basic Information
Provider Information | |||||||||
NPI: | 1821306309 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROVIDENCE COMMUNITY SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4918 ABBOTT RD | ||||||||
Address2: |   | ||||||||
City: | LYNWOOD | ||||||||
State: | CA | ||||||||
PostalCode: | 902622355 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5623968153 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4281 KATELLA AVE STE 201 | ||||||||
Address2: |   | ||||||||
City: | LOS ALAMITOS | ||||||||
State: | CA | ||||||||
PostalCode: | 907206509 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5624675440 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/19/2010 | ||||||||
LastUpdateDate: | 09/19/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OKUONGHA | ||||||||
AuthorizedOfficialFirstName: | NIKITA | ||||||||
AuthorizedOfficialMiddleName: | DAWN | ||||||||
AuthorizedOfficialTitleorPosition: | MENTAL HEALTH INTERN | ||||||||
AuthorizedOfficialTelephone: | 5623968153 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.