=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326409822
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY CRISIS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2016
-----------------------------------------------------
Last Update Date | 03/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2116 ARLINGTON AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90018-1353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-737-3900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2116 ARLINGTON AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90018-1353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL SUPERVISOR
-----------------------------------------------------
Name | REYNA DIAZ
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 323-737-3900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------