Provider Demographics
NPI:1407114986
Name:REAL CONNECTIONS CHILD DEVELOPMENT INSTITUTE
Entity Type:Organization
Organization Name:REAL CONNECTIONS CHILD DEVELOPMENT INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:ZEQUEIRA-RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:626-358-1564
Mailing Address - Street 1:140 E COLORADO BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-5145
Mailing Address - Country:US
Mailing Address - Phone:626-358-1564
Mailing Address - Fax:626-358-1641
Practice Address - Street 1:140 E COLORADO BLVD STE D
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-5145
Practice Address - Country:US
Practice Address - Phone:626-358-1564
Practice Address - Fax:626-358-1641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19727251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health