Basic Information
Provider Information | |||||||||
NPI: | 1538406186 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INSTITUTE FOR THE REDESIGN OF LEARNING | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 625 FAIR OAKS AVE | ||||||||
Address2: | #300 | ||||||||
City: | SOUTH PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 910302630 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3233415580 | ||||||||
FaxNumber: | 3233408298 | ||||||||
Practice Location | |||||||||
Address1: | 211 PASADENA AVE | ||||||||
Address2: |   | ||||||||
City: | SOUTH PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 910302919 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3233415580 | ||||||||
FaxNumber: | 3233408298 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/15/2013 | ||||||||
LastUpdateDate: | 10/22/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LAVELLE | ||||||||
AuthorizedOfficialFirstName: | NANCY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3233415580 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X |   |   | Y |   | Agencies | Day Training, Developmentally Disabled Services |   |
No ID Information.