Basic Information
| Provider Information | |||||||||
| NPI: | 1164976965 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FELICIANO-PINEDA | ||||||||
| FirstName: | FAE | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FELICIANO | ||||||||
| OtherFirstName: | FAE CASEYLINE | ||||||||
| OtherMiddleName: | FERNANDEZ | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3031 S VERMONT AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900073033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233732400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4401 CRENSHAW BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900431227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232908360 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2016 | ||||||||
| LastUpdateDate: | 10/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | ASW77979 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 103952 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.