Provider Demographics
NPI:1083681290
Name:MCLA PSYCHIATRIC MEDICAL GROUP A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MCLA PSYCHIATRIC MEDICAL GROUP A PROFESSIONAL CORPORATION
Other - Org Name:MCLA PSYCHIATRIC MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LUKAS
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEXANIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-240-0340
Mailing Address - Street 1:1560 E CHEVY CHASE DRIVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4140
Mailing Address - Country:US
Mailing Address - Phone:818-240-0340
Mailing Address - Fax:818-545-7672
Practice Address - Street 1:1560 E CHEVY CHASE DRIVE
Practice Address - Street 2:SUITE 130
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4140
Practice Address - Country:US
Practice Address - Phone:818-240-0340
Practice Address - Fax:818-545-7672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14960Medicare UPIN