Provider Demographics
NPI:1659839298
Name:NORTH EAST LOS ANGELES PSYCHOLOGY
Entity Type:Organization
Organization Name:NORTH EAST LOS ANGELES PSYCHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:310-571-8616
Mailing Address - Street 1:12360 RIVERSIDE DR APT 340
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3660
Mailing Address - Country:US
Mailing Address - Phone:310-314-0603
Mailing Address - Fax:
Practice Address - Street 1:380 S LAKE AVE STE 205
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-5063
Practice Address - Country:US
Practice Address - Phone:310-571-8616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-02
Last Update Date:2019-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health