=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457797953
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACIFIC TRAUMA TREATMENT CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2013
-----------------------------------------------------
Last Update Date | 05/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 444 S MARENGO AVE
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91101-3113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-738-4232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 81184
-----------------------------------------------------
City | SAN MARINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91118-1184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-738-4232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JACQUELINE GIANA WOODS
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 310-738-4232
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC46170
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------