Basic Information
| Provider Information | |||||||||
| NPI: | 1972776474 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MHA - TAY - CHILD AND FAMILY GUIDANCE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9650 ZELZAH AVE | ||||||||
| Address2: | |||||||||
| City: | NORTHRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913252003 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 310 E PALMDALE BLVD | ||||||||
| Address2: | |||||||||
| City: | PALMDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935507145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612658627 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2008 | ||||||||
| LastUpdateDate: | 08/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | ADLER | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF I.T. | ||||||||
| AuthorizedOfficialTelephone: | 8187395125 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 00200 | 05 | CA | MEDICAID |