Basic Information
| Provider Information | |||||||||
| NPI: | 1750368999 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UC REGENTS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UCLA NEUROPSYCHIATRIC BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE 2939 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108259989 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 300 MEDICAL PLAZA | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108259989 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 08/31/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GITLIN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PROF OF CLIN PSY CHAIR & DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3108259989 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0805X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 235Z00000X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 103TA0700X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging |
ID Information
| ID | Type | State | Issuer | Description | GPS000090 | 05 | CA | MEDICAID | GR0053840 | 05 | CA | MEDICAID | GSP000650 | 05 | CA | MEDICAID |