Basic Information
| Provider Information | |||||||||
| NPI: | 1902034101 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAUSD 97TH ST SMH CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 S BEAUDRY AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900171466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2132413841 | ||||||||
| FaxNumber: | 2132413305 | ||||||||
| Practice Location | |||||||||
| Address1: | 439 W 97TH ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900033968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237542856 | ||||||||
| FaxNumber: | 3237541843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2009 | ||||||||
| LastUpdateDate: | 06/25/2009 | ||||||||
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| AuthorizedOfficialLastName: | ESCUDERO | ||||||||
| AuthorizedOfficialFirstName: | PIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2132413841 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 163WP0808X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 1041C0700X | 0315 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0315 | 01 | CA | LA CTY ENTITY | OTHER |