Provider Demographics
NPI:1760862320
Name:LOS ANGELES COUNTY DEPARTMENT OF MENTAL HEALTH
Entity Type:Organization
Organization Name:LOS ANGELES COUNTY DEPARTMENT OF MENTAL HEALTH
Other - Org Name:JACQUELINE AVANT WELLBEING CENTER MEDICAL HUB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:H
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:213-947-6670
Mailing Address - Street 1:510 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-1992
Mailing Address - Country:US
Mailing Address - Phone:213-947-6670
Mailing Address - Fax:
Practice Address - Street 1:1741 E 120TH STREET
Practice Address - Street 2:1ST FL
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3051
Practice Address - Country:US
Practice Address - Phone:424-758-9101
Practice Address - Fax:310-223-0728
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOS ANGELES COUNTY DEPARTMENT OF MENTAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-08
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7916Medicaid