Basic Information
Provider Information | |||||||||
NPI: | 1669039368 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HATHAWAY SYCAMORES CHILD AND FAMILY SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SYCAMORES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 W WALNUT ST STE 375 | ||||||||
Address2: |   | ||||||||
City: | PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 911240001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6263957100 | ||||||||
FaxNumber: | 6263957270 | ||||||||
Practice Location | |||||||||
Address1: | 12540 PIERCE ST | ||||||||
Address2: |   | ||||||||
City: | PACOIMA | ||||||||
State: | CA | ||||||||
PostalCode: | 913311701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6263957100 | ||||||||
FaxNumber: | 6263957270 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/29/2019 | ||||||||
LastUpdateDate: | 07/02/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MANNERS | ||||||||
AuthorizedOfficialFirstName: | DEBBIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
AuthorizedOfficialTelephone: | 6263957100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HATHAWAY SYCAMORES CHILD AND FAMILY SERVICES | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LCSW | ||||||||
NPICertificationDate: | 07/02/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   | 163WP0808X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 164X00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Nursing Service Providers | Licensed Vocational Nurse |   | 167G00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Nursing Service Providers | Licensed Psychiatric Technician |   | 174400000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   | 2084P0800X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 208D00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   | 225400000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |   | 374700000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Nursing Service Related Providers | Technician |   | 101YM0800X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.