Healthcare Provider Details

I. General information

NPI: 1033301221
Provider Name (Legal Business Name): CHILDREN HOSPITAL LOS ANGELES MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 WILSHIRE BLVD SUITES 300, 320, 500 & 600
LOS ANGELES CA
90010-1577
US

IV. Provider business mailing address

3250 WILSHIRE BLVD SUITE 300, 320, 500 & 600
LOS ANGELES CA
90010-1577
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-3849
  • Fax: 323-361-7081
Mailing address:
  • Phone: 323-361-3849
  • Fax: 323-361-7081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARISA GLUCOFT
Title or Position: VICE PRESIDENT, QUALITY AND SAFETY
Credential:
Phone: 323-361-3356