=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093161218
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TONYA M. JAVADI, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2016
-----------------------------------------------------
Last Update Date | 05/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 E GRAND AVE
-----------------------------------------------------
City | EL SEGUNDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90245-3841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-819-7332
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 E GRAND AVE
-----------------------------------------------------
City | EL SEGUNDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90245-3841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-819-7332
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | TONYA JAVADI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-819-7332
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCSW5470
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT37168
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT40403
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------