Basic Information
| Provider Information | |||||||||
| NPI: | 1902920176 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HILLSIDES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HILLSIDES FAMILY RESOURCE CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 149 PASADENA AVE STE A | ||||||||
| Address2: | |||||||||
| City: | SOUTH PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910303351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232743065 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 149 PASADENA AVE STE A | ||||||||
| Address2: | |||||||||
| City: | SOUTH PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910303351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232542274 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 01/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROTH | ||||||||
| AuthorizedOfficialFirstName: | STACEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3235432800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HILLSIDES | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 01/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.