Basic Information
Provider Information | |||||||||
NPI: | 1922656131 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | D'VEAL FAMILY AND YOUTH SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DFYS SANTA FE COMPUTER MAGNET SCH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2750 E WASHINGTON BLVD STE 230 | ||||||||
Address2: |   | ||||||||
City: | PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 911071449 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6262968900 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 148 W DUARTE RD | ||||||||
Address2: |   | ||||||||
City: | MONROVIA | ||||||||
State: | CA | ||||||||
PostalCode: | 910164539 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6262968900 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2019 | ||||||||
LastUpdateDate: | 09/03/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GROSS | ||||||||
AuthorizedOfficialFirstName: | ZERRI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | QA/QI SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 6262968900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | D'VEAL FAMILY AND YOUTH SERVICES | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LMFT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.