=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245394121
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNSELING CENTER OF SANTA MONICA - A PSYCHOLOGICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2006
-----------------------------------------------------
Last Update Date | 12/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1321 9TH ST
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90401-1803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-477-6000
-----------------------------------------------------
Fax | 310-477-0327
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1321 9TH ST
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90401-1803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-477-6000
-----------------------------------------------------
Fax | 310-477-0327
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT - OWNER
-----------------------------------------------------
Name | DR. REUBEN VAISMAN-TZACHOR
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 310-477-6000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | PSY 15091
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
-----------------------------------------------------
License Number | PSY 15091
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TA0700X
-----------------------------------------------------
Taxonomy Name | Adult Development & Aging Psychologist
-----------------------------------------------------
License Number | PSY 15091
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TB0200X
-----------------------------------------------------
Taxonomy Name | Cognitive & Behavioral Psychologist
-----------------------------------------------------
License Number | PSY 15091
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY 15091
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | PSY 15091
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | PSY 15091
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 103TE1100X
-----------------------------------------------------
Taxonomy Name | Exercise & Sports Psychologist
-----------------------------------------------------
License Number | PSY 15091
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 103TF0000X
-----------------------------------------------------
Taxonomy Name | Family Psychologist
-----------------------------------------------------
License Number | PSY 15091
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 103TF0200X
-----------------------------------------------------
Taxonomy Name | Forensic Psychologist
-----------------------------------------------------
License Number | PSY 15091
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #11
-----------------------------------------------------
Taxonomy Code | 103TP2701X
-----------------------------------------------------
Taxonomy Name | Group Psychotherapy Psychologist
-----------------------------------------------------
License Number | PSY 15091
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #12
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY 15091
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------