=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467792341
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLINICAL AFFILIATES A LICENSED CLINICAL SOCIAL WORKERS CORP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2013
-----------------------------------------------------
Last Update Date | 06/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 737 HALLIDAY AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90049-2041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-440-5050
-----------------------------------------------------
Fax | 818-787-5870
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 737 HALLIDAY AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90049-2041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-440-5050
-----------------------------------------------------
Fax | 818-787-5870
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ROSALYN BENITEZ-BLOCH
-----------------------------------------------------
Credential | D.S.W.
-----------------------------------------------------
Telephone | 310-440-5050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW2857
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------