Healthcare Provider Details

I. General information

NPI: 1366082844
Provider Name (Legal Business Name): CALIFORNIA INSTITUTE OF HEALTH & SOCIAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2020
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3756 SANTA ROSALIA DR STE 628
LOS ANGELES CA
90008-3606
US

IV. Provider business mailing address

8939 S SEPULVEDA BLVD STE 401
LOS ANGELES CA
90045-3646
US

V. Phone/Fax

Practice location:
  • Phone: 323-293-8771
  • Fax:
Mailing address:
  • Phone: 310-645-5227
  • Fax: 310-645-9840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. CYNTHIA MARSHALL
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 310-645-5227