Basic Information
| Provider Information | |||||||||
| NPI: | 1902153455 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CALVILLO | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 679 S NEW HAMPSHIRE AVE STE 350 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900051355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8184476997 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 679 S NEW HAMPSHIRE AVE STE 350 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2133855100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2012 | ||||||||
| LastUpdateDate: | 11/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 34422 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | 86442 | CA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.