Healthcare Provider Details

I. General information

NPI: 1114331139
Provider Name (Legal Business Name): COUNTY OF LOS ANGELES DEPARTMENT OF MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 06/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 EASTLAKE AVE 2ND FLOOR
LOS ANGELES CA
90033-1009
US

IV. Provider business mailing address

1605 EASTLAKE AVENUE 2ND FLOOR
LOS ANGELES CA
90033
US

V. Phone/Fax

Practice location:
  • Phone: 323-226-8826
  • Fax: 323-226-8820
Mailing address:
  • Phone: 323-226-8826
  • Fax: 323-226-8820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. MARVIN J SOUTHARD, D.S.W.
Title or Position: DIRECTOR
Credential: D.S.W.
Phone: 213-738-4601