Healthcare Provider Details

I. General information

NPI: 1992997597
Provider Name (Legal Business Name): PACIFIC FORENSIC PSYCHOLOGY ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 08/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 SHATTO PL
LOS ANGELES CA
90005-1301
US

IV. Provider business mailing address

616 SHATTO PL
LOS ANGELES CA
90005-1301
US

V. Phone/Fax

Practice location:
  • Phone: 213-738-8853
  • Fax: 213-738-5368
Mailing address:
  • Phone: 213-738-8853
  • Fax: 213-738-5368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. LEA CHANKIN
Title or Position: DIRECTOR
Credential: PSY.D.
Phone: 213-738-8853