Basic Information
Provider Information | |||||||||
NPI: | 1841519055 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HATHWAY SYCAMORES CHILD AND FAMILY SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COMMUNITY ALCOHOL AND DRUG TREATMENT FOUNDATION | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15015 OXNARD ST | ||||||||
Address2: |   | ||||||||
City: | VAN NUYS | ||||||||
State: | CA | ||||||||
PostalCode: | 914112613 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8187874151 | ||||||||
FaxNumber: | 8187872840 | ||||||||
Practice Location | |||||||||
Address1: | 2933 EL NIDO DR | ||||||||
Address2: |   | ||||||||
City: | ALTADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 910014529 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8187874151 | ||||||||
FaxNumber: | 8187872840 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/27/2010 | ||||||||
LastUpdateDate: | 12/14/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MACIAS | ||||||||
AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
AuthorizedOfficialMiddleName: | JADE | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8187874151 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | VAN NUYS TREATMENT CENTER | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | B.A. LIBERAL STUDIES | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 190327AP | CA | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.