=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356880462
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACORN FAMILY GUIDANCE CENTER, A PROFESSIONAL PSYCHOLOGICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2017
-----------------------------------------------------
Last Update Date | 02/22/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12777 W JEFFERSON BLVD BUILDING D, SUITE 300
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90066-7048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-289-2725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12777 W JEFFERSON BLVD BUILDING D, SUITE 300
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90066-7048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-289-2725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL CHILD PSYCHOLOGIST
-----------------------------------------------------
Name | DR. CARIN LAUE
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 424-289-2725
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | PSY28903
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------