1154933026 NPI number — LA CONCORDIA PSYCHOTHERAPY AND WELLNESS CLINIC

Table of content: (NPI 1154933026)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154933026 NPI number — LA CONCORDIA PSYCHOTHERAPY AND WELLNESS CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LA CONCORDIA PSYCHOTHERAPY AND WELLNESS CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154933026
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1070 CONCORD AVE STE 109
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONCORD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94520-5608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-849-5349
Provider Business Mailing Address Fax Number:
925-270-3382

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1070 CONCORD AVE STE 109
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONCORD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94520-5608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-849-5349
Provider Business Practice Location Address Fax Number:
925-270-3382
Provider Enumeration Date:
08/20/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FERNANDEZ
Authorized Official First Name:
RUTH
Authorized Official Middle Name:
ALEJANDRA
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
925-849-4695

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1750641189 . This is a "NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1558558676 . This is a "NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1588997035 . This is a "NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".