Healthcare Provider Details

I. General information

NPI: 1588421192
Provider Name (Legal Business Name): PROGRAM FOR TORTURE VICTIMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/29/2024
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 E 17TH ST STE 222
SANTA ANA CA
92705-8520
US

IV. Provider business mailing address

3550 WILSHIRE BLVD STE 1960
LOS ANGELES CA
90010-2401
US

V. Phone/Fax

Practice location:
  • Phone: 213-384-4788
  • Fax:
Mailing address:
  • Phone: 213-384-4788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANA GRANDE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 213-384-4788