Basic Information
| Provider Information | |||||||||
| NPI: | 1578002374 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LOS ANGELES COUNTY DEPARTMENT OF MENTAL HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AFH - MLK FIRST 5 PCIT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 510 S VERMONT AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900201992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2137384601 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1721 E 120TH ST TRLR 6 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4243382929 | ||||||||
| FaxNumber: | 3102230319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2017 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WONG | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | ACTING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2137384601 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LOS ANGELES COUNTY DEPARTMENT OF MENTAL HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PSY.D. | ||||||||
| NPICertificationDate: | 09/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 6864P | 05 | CA | MEDICAID |