Provider Demographics
NPI:1629272026
Name:KAISER PERMANENTE
Entity Type:Organization
Organization Name:KAISER PERMANENTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOTHERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DELORRELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MFT
Authorized Official - Phone:323-298-3100
Mailing Address - Street 1:10876 MARIETTA AVE
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-3714
Mailing Address - Country:US
Mailing Address - Phone:310-836-7195
Mailing Address - Fax:
Practice Address - Street 1:5105 W GOLDLEAF CIR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90056-1269
Practice Address - Country:US
Practice Address - Phone:323-298-3100
Practice Address - Fax:323-298-3119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 29835302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization