Healthcare Provider Details

I. General information

NPI: 1588782502
Provider Name (Legal Business Name): INSTITUTE FOR THE REDESIGN OF LEARNING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 11/11/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 HUNTINGTON DR
SOUTH PASADENA CA
91030-4511
US

IV. Provider business mailing address

1317 HUNTINGTON DR
SOUTH PASADENA CA
91030-4511
US

V. Phone/Fax

Practice location:
  • Phone: 323-341-7777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SELENE LAWS
Title or Position: SR. CONTRACT ADMINISTRATOR
Credential:
Phone: 323-344-5536