Basic Information
| Provider Information | |||||||||
| NPI: | 1912117938 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALIFORNIA INSTITUTE OF HEALTH & SOCIAL SERVICES, INC | ||||||||
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| OtherOrganizationName: | ENLIGHTENMENT CHEMICAL DEPENDENCY PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8929 S SEPULVEDA BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900453616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106455227 | ||||||||
| FaxNumber: | 3106450833 | ||||||||
| Practice Location | |||||||||
| Address1: | 3756 SANTA ROSALIA DR | ||||||||
| Address2: | SUITE 628 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900083606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232938771 | ||||||||
| FaxNumber: | 3106450833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 06/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | TISDALE | ||||||||
| AuthorizedOfficialFirstName: | ARTHUR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | REG ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 3106455227 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CALIFORNIA INSTITUTE OF HEALTH & SOCIAL SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | PSY.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.