Provider Demographics
NPI:1558672360
Name:CALIFORNIA MENTAL HEALTH CONNECTION
Entity Type:Organization
Organization Name:CALIFORNIA MENTAL HEALTH CONNECTION
Other - Org Name:CALIFORNIA MENTAL HEALTH CONNECTION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL RESEARCH COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELISA
Authorized Official - Middle Name:K
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD INTERN, LICENSE
Authorized Official - Phone:626-453-6234
Mailing Address - Street 1:2217 CALLE PARRAL
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792
Mailing Address - Country:US
Mailing Address - Phone:626-203-1449
Mailing Address - Fax:626-430-7404
Practice Address - Street 1:714 N. SUNSET AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790
Practice Address - Country:US
Practice Address - Phone:626-453-6234
Practice Address - Fax:626-430-7404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-25
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA198601281261Q00000X, 320800000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental IllnessGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
198601281OtherSTATE OF CALIFORNIA DPT OF SOCIAL SERVICES