Healthcare Provider Details

I. General information

NPI: 1376913400
Provider Name (Legal Business Name): THE CAMDEN CENTER OLDER ADULTS PROGRAM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2015
Last Update Date: 10/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10780 SANTA MONICA BLVD STE 105
LOS ANGELES CA
90025-7613
US

IV. Provider business mailing address

10780 SANTA MONICA BLVD STE 105
LOS ANGELES CA
90025-7613
US

V. Phone/Fax

Practice location:
  • Phone: 844-422-6336
  • Fax: 888-887-2955
Mailing address:
  • Phone: 844-422-6336
  • Fax: 888-887-2955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPSB4021549
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA112538
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number39712
License Number StateCA

VIII. Authorized Official

Name: MISS JESSICA KLEIN
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 844-422-6336