Provider Demographics
NPI:1669841490
Name:NEW ANTIOCH COGIC
Entity Type:Organization
Organization Name:NEW ANTIOCH COGIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LAQUITA
Authorized Official - Middle Name:S
Authorized Official - Last Name:SUGGS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:323-778-7965
Mailing Address - Street 1:7826 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-3530
Mailing Address - Country:US
Mailing Address - Phone:323-778-7965
Mailing Address - Fax:
Practice Address - Street 1:7826 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-3530
Practice Address - Country:US
Practice Address - Phone:323-778-7965
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW204591041C0700X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty