Basic Information
Provider Information | |||||||||
NPI: | 1881627420 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LOS ANGELES COUNTY DEPARTMENT OF MENTAL HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PALMDALE MENTAL HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 510 S VERMONT AVE | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900201992 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2317384601 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1529 E PALMDALE BLVD, STE 150 | ||||||||
Address2: |   | ||||||||
City: | PALMDALE | ||||||||
State: | CA | ||||||||
PostalCode: | 935502038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6615751800 | ||||||||
FaxNumber: | 6615372932 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/08/2006 | ||||||||
LastUpdateDate: | 07/15/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WONG | ||||||||
AuthorizedOfficialFirstName: | LISA | ||||||||
AuthorizedOfficialMiddleName: | H. | ||||||||
AuthorizedOfficialTitleorPosition: | ACTING DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2137384601 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ANGELES COUNTY DEPARTMENT OF MENTAL HEALTH | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PSY.D. | ||||||||
NPICertificationDate: | 07/15/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 7386 | 05 | CA |   | MEDICAID |