Basic Information
| Provider Information | |||||||||
| NPI: | 1265781926 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLOUD | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | ELI | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11728 LEMOLI AVE | ||||||||
| Address2: | |||||||||
| City: | INGLEWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 903033028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109227953 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3756 SANTA ROSALIA DR STE 628 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900083606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232938771 | ||||||||
| FaxNumber: | 3232938780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2012 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 101YM0800X | 94445 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1265781926 | 01 | CA | VISTA DEL MAR | OTHER |