Basic Information
| Provider Information | |||||||||
| NPI: | 1386776110 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHIELDS FOR FAMILIES SCHOOL BASE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11601 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900475006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232425000 | ||||||||
| FaxNumber: | 3232425011 | ||||||||
| Practice Location | |||||||||
| Address1: | 161 W VICTORIA ST | ||||||||
| Address2: | SUITE 255 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908052175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232425000 | ||||||||
| FaxNumber: | 3232425011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 04/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | ICENHOWER | ||||||||
| AuthorizedOfficialFirstName: | KATHRYN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3232425000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
| NPICertificationDate: | 04/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 7536 | 05 | CA | MEDICAID |