Healthcare Provider Details

I. General information

NPI: 1518288570
Provider Name (Legal Business Name): PASADENA CHILD DEVELOPMENT ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2010
Last Update Date: 06/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N LAKE AVE
PASADENA CA
91101-1220
US

IV. Provider business mailing address

620 N LAKE AVE
PASADENA CA
91101-1220
US

V. Phone/Fax

Practice location:
  • Phone: 626-793-7350
  • Fax: 626-793-7341
Mailing address:
  • Phone: 626-793-7350
  • Fax: 626-793-7341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. DIANE CULLINANE
Title or Position: EXECUTIVE DIRECTOR
Credential: M.D.
Phone: 626-793-7350