Basic Information
Provider Information
NPI: 1285995860
EntityType: 2
ReplacementNPI:  
OrganizationName: EMOTIONAL HEALTH ASSOCIATION
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: SHARE
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 6666 GREEN VALLEY CIR
Address2:  
City: CULVER CITY
State: CA
PostalCode: 90230
CountryCode: US
TelephoneNumber: 3108465270
FaxNumber: 3108465278
Practice Location
Address1: 6666 GREEN VALLEY CIR
Address2:  
City: CULVER CITY
State: CA
PostalCode: 902307068
CountryCode: US
TelephoneNumber: 3108465270
FaxNumber: 3108465278
Other Information
ProviderEnumerationDate: 05/31/2012
LastUpdateDate: 05/31/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: THOMPSON
AuthorizedOfficialFirstName: RICKY
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: VOLUNTEER COORDINATOR
AuthorizedOfficialTelephone: 2132130100
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YM0800X  Y193200000X MULTI-SPECIALTY GROUPBehavioral Health & Social Service ProvidersCounselorMental Health

No ID Information.


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