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General NPI Number Information
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NPI Number | 1972375715
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Entity Type | Organization
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Legal Business Name | SOCAL ADOLESCENT WELLNESS, INC.
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Dates
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Enumeration Date | 10/25/2023
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Last Update Date | 10/25/2023
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Provider Practice Location Address
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Address Line | 22471 ASPAN ST STE 110
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City | LAKE FOREST
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State | CA
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Zip | 92630-1644
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Country | US
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Telephone | 714-465-2305
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Fax |
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Provider Business Mailing Address
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Address Line | 16168 BEACH BLVD STE 170
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City | HUNTINGTON BEACH
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State | CA
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Zip | 92647-3878
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CFO
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Name | REBECCA M HARRIS
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Credential |
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Telephone | 949-467-4324
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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