Provider Demographics
NPI:1194850842
Name:TESSIE CLEVELAND COMMUNITY SERVICES CORPORATION
Entity Type:Organization
Organization Name:TESSIE CLEVELAND COMMUNITY SERVICES CORPORATION
Other - Org Name:TESSIE CLEVELAND COMMUNITY SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHADWICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-586-7333
Mailing Address - Street 1:8019 S. COMPTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90001-3409
Mailing Address - Country:US
Mailing Address - Phone:323-586-7333
Mailing Address - Fax:
Practice Address - Street 1:8019 S. COMPTON AVENUE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90001-3409
Practice Address - Country:US
Practice Address - Phone:323-586-7333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7641Medicaid