Provider Demographics
NPI:1619551124
Name:SOCAL ADOLESCENT WELLNESS, INC.
Entity Type:Organization
Organization Name:SOCAL ADOLESCENT WELLNESS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-467-4324
Mailing Address - Street 1:16052 BEACH BLVD STE 135
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-3817
Mailing Address - Country:US
Mailing Address - Phone:714-465-5583
Mailing Address - Fax:
Practice Address - Street 1:16168 BEACH BLVD STE 170
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-3878
Practice Address - Country:US
Practice Address - Phone:714-465-5583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health