Healthcare Provider Details

I. General information

NPI: 1750368999
Provider Name (Legal Business Name): UC REGENTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 08/31/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MEDICAL PLAZA
LOS ANGELES CA
90095
US

IV. Provider business mailing address

FILE 2939
LOS ANGELES CA
90074
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-9989
  • Fax:
Mailing address:
  • Phone: 310-825-9989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateCA

VIII. Authorized Official

Name: MICHAEL J GITLIN
Title or Position: PROF OF CLIN PSY CHAIR & DIRECTOR
Credential: MD
Phone: 310-825-9989