Basic Information
| Provider Information | |||||||||
| NPI: | 1639201031 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHIELDS FOR FAMILIES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
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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: | 2620 INDUSTRY WAY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LYNWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902624024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232425000 | ||||||||
| FaxNumber: | 3232425011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 04/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/12/2019 | ||||||||
| NPIReactivationDate: | 11/13/2019 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ICENHOWER | ||||||||
| AuthorizedOfficialFirstName: | KATHRYN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3232425000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PH.D. | ||||||||
| NPICertificationDate: | 04/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 7365 | 01 | CA | MEDI-CAL PROVIDER NUMBER | OTHER |