=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245360130
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEHAVIORAL HEALTH SERVICES INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2501 W EL SEGUNDO BLVD
-----------------------------------------------------
City | HAWTHORNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90250-3317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-754-2816
-----------------------------------------------------
Fax | 323-754-2828
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15519 CRENSHAW BLVD
-----------------------------------------------------
City | GARDENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90249-4525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-679-9126
-----------------------------------------------------
Fax | 310-679-2920
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE VICE PRESIDENT
-----------------------------------------------------
Name | MS. TERI CANNON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-679-9126
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 190007GN
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------