Basic Information
| Provider Information | |||||||||
| NPI: | 1902109820 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROTOTYPES CENTERS FOR INNOVATION IN HEALTH, MH, & SOCIAL SERVICES | ||||||||
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| OtherOrganizationName: | PROTOTYPES CENTERS FOR INNOVATION IN 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: | 11100 VALLEY BLVD | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | EL MONTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917312500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264440705 | ||||||||
| FaxNumber: | 6264440710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2010 | ||||||||
| LastUpdateDate: | 12/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | LOCH | ||||||||
| AuthorizedOfficialFirstName: | CASSANDRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 2135423838 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW, MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.