Basic Information
| Provider Information | |||||||||
| NPI: | 1669641239 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UC REGENTS UCLA NPBH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455632 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 760 WESTWOOD PLZ | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900958353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108259989 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2008 | ||||||||
| LastUpdateDate: | 05/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | CLIFFORD | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | GROUP AUTHORIZER | ||||||||
| AuthorizedOfficialTelephone: | 3108259989 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | SP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | GSP000650 | 05 | CA | MEDICAID |