Basic Information
Provider Information | |||||||||
NPI: | 1033238944 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHILD GUIDANCE CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CYS CHILD GUIDANCE CENTER, INC., EAST | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 525 CABRILLO PARK DR | ||||||||
Address2: | SUITE 300 | ||||||||
City: | SANTA ANA | ||||||||
State: | CA | ||||||||
PostalCode: | 927015017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7149534455 | ||||||||
FaxNumber: | 7145478855 | ||||||||
Practice Location | |||||||||
Address1: | 525 CABRILLO PARK DR | ||||||||
Address2: | SUITE 300 | ||||||||
City: | SANTA ANA | ||||||||
State: | CA | ||||||||
PostalCode: | 927015017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7149534455 | ||||||||
FaxNumber: | 7145478855 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2007 | ||||||||
LastUpdateDate: | 07/13/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PACK | ||||||||
AuthorizedOfficialFirstName: | LORI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 7149534455 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MISS | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LCSW | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 910-1912-5 | CA | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 910-1912-5 | 01 | CA | STATE ID | OTHER |