Basic Information
| Provider Information | |||||||||
| NPI: | 1578800280 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHIELDS FOR FAMILIES | ||||||||
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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: | 11705 DEPUTY YAMAMOTO PL STE A | ||||||||
| Address2: | |||||||||
| City: | LYNWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902624031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233576930 | ||||||||
| FaxNumber: | 3235691979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2013 | ||||||||
| LastUpdateDate: | 04/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | ICENHOWER | ||||||||
| AuthorizedOfficialFirstName: | KATHRYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3232425000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | 04/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.