Basic Information
| Provider Information | |||||||||
| NPI: | 1861675431 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROTOTYPES CENTERS FOR INNOVATION - HEALTH, MH, & SOCIAL SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROTOTYPES CENTERS - HEALTH, MH, & SOCIAL SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 N ALAMEDA ST | ||||||||
| Address2: | SUITE 390 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900121804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2135423838 | ||||||||
| FaxNumber: | 2132250085 | ||||||||
| Practice Location | |||||||||
| Address1: | 1890 N GAREY AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917672923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096292400 | ||||||||
| FaxNumber: | 9096292445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2007 | ||||||||
| LastUpdateDate: | 11/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | LOCH | ||||||||
| AuthorizedOfficialFirstName: | CASSANDRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT, CEO | ||||||||
| AuthorizedOfficialTelephone: | 2135423838 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW, MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 7568A | 01 | CA | LA COUNTY DMH | OTHER |