Healthcare Provider Details

I. General information

NPI: 1083733745
Provider Name (Legal Business Name): THE REGENTS OF THE UNIVERSITY OF CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 VETERAN AVE BX 714222
LOS ANGELES CA
90095-7142
US

IV. Provider business mailing address

1000 VETERAN AVE 714222
LOS ANGELES CA
90095-7142
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-6110
  • Fax: 310-794-4996
Mailing address:
  • Phone: 310-825-6110
  • Fax: 310-794-4996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: AUDRA LANGLEY
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D
Phone: 310-794-2460