Provider Demographics
NPI:1083914162
Name:CALZADILLA PSYCHOLOGICAL INC
Entity Type:Organization
Organization Name:CALZADILLA PSYCHOLOGICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARYLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CALZADILLA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:818-968-5564
Mailing Address - Street 1:PO BOX 251377
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91225-1377
Mailing Address - Country:US
Mailing Address - Phone:310-325-4415
Mailing Address - Fax:310-326-3744
Practice Address - Street 1:1530 E CHEVY CHASE DR
Practice Address - Street 2:SUITE 204
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4163
Practice Address - Country:US
Practice Address - Phone:310-325-4415
Practice Address - Fax:310-326-3744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-23
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17154103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP17154Medicare PIN
CACP17154AMedicare PIN