Basic Information
Provider Information | |||||||||
NPI: | 1811392087 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DE LOS SANTOS | ||||||||
FirstName: | ELIDIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DE LOS SANTOS RAMOS | ||||||||
OtherFirstName: | ELIDIA | ||||||||
OtherMiddleName: | ELIVIER | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2592 | ||||||||
Address2: |   | ||||||||
City: | INGLEWOOD | ||||||||
State: | CA | ||||||||
PostalCode: | 903050592 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2134817464 | ||||||||
FaxNumber: | 2134817147 | ||||||||
Practice Location | |||||||||
Address1: | 2311 W EL SEGUNDO BLVD | ||||||||
Address2: |   | ||||||||
City: | HAWTHORNE | ||||||||
State: | CA | ||||||||
PostalCode: | 902503315 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3109705000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/29/2014 | ||||||||
LastUpdateDate: | 03/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | ASW63256 | CA | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 99289 | CA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.