Provider Demographics
NPI:1619544988
Name:PRUDENT TELEPSYCHIATRY CARE A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PRUDENT TELEPSYCHIATRY CARE A MEDICAL CORPORATION
Other - Org Name:PRUDENT TELEPSYCHIATRY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FELISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANUGOM
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP, FNP
Authorized Official - Phone:866-214-7214
Mailing Address - Street 1:16660 PARAMOUNT BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-5458
Mailing Address - Country:US
Mailing Address - Phone:866-214-7214
Mailing Address - Fax:866-214-8786
Practice Address - Street 1:16660 PARAMOUNT BLVD STE 208
Practice Address - Street 2:
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723-5458
Practice Address - Country:US
Practice Address - Phone:323-632-5868
Practice Address - Fax:866-214-8786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-07
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty