=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700359981
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THERAPY LAB, INC., A PSYCHOLOGICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2019
-----------------------------------------------------
Last Update Date | 01/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 E 1ST ST STE 300
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90012-3819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-455-8080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 250 E 1ST ST STE 300
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90012-3819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-455-8080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. N. CHANDLER SIMS CHANG
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 323-455-8080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TB0200X
-----------------------------------------------------
Taxonomy Name | Cognitive & Behavioral Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------