Basic Information
| Provider Information | |||||||||
| NPI: | 1265950455 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HATHAWAY SYCAMORES CHILD AND FAMILY SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | SYCAMORES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 W WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911240001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263957100 | ||||||||
| FaxNumber: | 6263957270 | ||||||||
| Practice Location | |||||||||
| Address1: | 1603 S MARGUERITA AVE | ||||||||
| Address2: | |||||||||
| City: | ALHAMBRA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 918033148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262431560 | ||||||||
| FaxNumber: | 6267994596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2017 | ||||||||
| LastUpdateDate: | 07/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MANNERS | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 6263957100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HATHAWAY SYCAMORES CHILD AND FAMILY SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 07/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 163WP0808X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.