1992169940 NPI number — KEYSTONE PEDIATRIC BEHAVIORAL HEALTH

Table of content: (NPI 1992169940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992169940 NPI number — KEYSTONE PEDIATRIC BEHAVIORAL HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEYSTONE PEDIATRIC BEHAVIORAL HEALTH
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:
1992169940
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 TEMPLE AVE
Provider Second Line Business Mailing Address:
APT 26
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90814-1255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-356-8600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
610 PACIFIC COAST HWY
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
SEAL BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90740-6604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-356-8600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/06/2016

Additional Information

Authorized Official

Authorized Official Last Name:
OCEN
Authorized Official First Name:
MICHELE
Authorized Official Middle Name:
AUDREY
Authorized Official Title or Position:
PSYCHOLOGIST/ BCBA
Authorized Official Telephone Number:
562-356-8600

Provider Taxonomy Codes

  • Taxonomy code: 103TM1800X , with the licence number:  27081 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com