Provider Demographics
NPI: | 1245394121 |
---|---|
Name: | COUNSELING CENTER OF SANTA MONICA - A PSYCHOLOGICAL CORPORATION |
Entity Type: | Organization |
Organization Name: | COUNSELING CENTER OF SANTA MONICA - A PSYCHOLOGICAL CORPORATION |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT - OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | REUBEN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | VAISMAN-TZACHOR |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | PHD |
Authorized Official - Phone: | 310-477-6000 |
Mailing Address - Street 1: | 1321 9TH ST |
Mailing Address - Street 2: | |
Mailing Address - City: | SANTA MONICA |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 90401-1803 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 310-477-6000 |
Mailing Address - Fax: | 310-477-0327 |
Practice Address - Street 1: | 1321 9TH ST |
Practice Address - Street 2: | |
Practice Address - City: | SANTA MONICA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 90401-1803 |
Practice Address - Country: | US |
Practice Address - Phone: | 310-477-6000 |
Practice Address - Fax: | 310-477-0327 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-12-21 |
Last Update Date: | 2008-12-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | PSY 15091 | 103G00000X, 103T00000X, 103TA0400X, 103TA0700X, 103TB0200X, 103TC0700X, 103TC1900X, 103TC2200X, 103TE1100X, 103TF0000X, 103TF0200X, 103TP2701X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
No | 103G00000X | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | Group - Multi-Specialty | |
No | 103TA0400X | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
No | 103TA0700X | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging | Group - Multi-Specialty |
No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | Group - Multi-Specialty |
No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
No | 103TC1900X | Behavioral Health & Social Service Providers | Psychologist | Counseling | Group - Multi-Specialty |
No | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | Group - Multi-Specialty |
No | 103TE1100X | Behavioral Health & Social Service Providers | Psychologist | Exercise & Sports | Group - Multi-Specialty |
No | 103TF0000X | Behavioral Health & Social Service Providers | Psychologist | Family | Group - Multi-Specialty |
No | 103TF0200X | Behavioral Health & Social Service Providers | Psychologist | Forensic | Group - Multi-Specialty |
No | 103TP2701X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | ========= | Other | BLUE CROSS ID NUMBER |