Basic Information
| Provider Information | |||||||||
| NPI: | 1255459202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDEN | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | RUSSELL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 S LA FAYETTE PARK PL | ||||||||
| Address2: | APT 412 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900575413 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 711 S NEW HAMPSHIRE AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900051831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2133855100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 07/09/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 61942 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.