Healthcare Provider Details

I. General information

NPI: 1205140548
Provider Name (Legal Business Name): PEDIATRIC MINDS MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2010
Last Update Date: 09/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3524 TORRANCE BLVD SUITE 103
TORRANCE CA
90503-4821
US

IV. Provider business mailing address

3524 TORRANCE BLVD SUITE 103
TORRANCE CA
90503-4821
US

V. Phone/Fax

Practice location:
  • Phone: 310-540-1630
  • Fax: 310-543-0400
Mailing address:
  • Phone: 310-540-1630
  • Fax: 310-543-0400

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 Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberA78624
License Number StateCA

VIII. Authorized Official

Name: MARIA APODACA
Title or Position: ACCOUNT REPRESENTATIVE
Credential:
Phone: 424-206-1919