=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467527747
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEPARTMENT OF MENTAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2006
-----------------------------------------------------
Last Update Date | 09/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1720 E 120TH ST ROOM 1099
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90059-3052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-668-5059
-----------------------------------------------------
Fax | 310-223-0914
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1720 E 120TH ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90059-3052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-668-5059
-----------------------------------------------------
Fax | 310-223-0914
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHIATRIC SOCIAL WORKER
-----------------------------------------------------
Name | MS. SUESAN COLEMAN
-----------------------------------------------------
Credential | MASTERS DEGREE
-----------------------------------------------------
Telephone | 310-668-5059
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 11812
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------