Provider Demographics
NPI:1801233432
Name:BETHANY CHRISTIAN SERVICES OF SOUTHERN CALIFORNIA, INC.
Entity Type:Organization
Organization Name:BETHANY CHRISTIAN SERVICES OF SOUTHERN CALIFORNIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BRANCH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:714-994-0500
Mailing Address - Street 1:16700 VALLEY VIEW AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-5830
Mailing Address - Country:US
Mailing Address - Phone:714-994-0500
Mailing Address - Fax:714-994-0515
Practice Address - Street 1:16700 VALLEY VIEW AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-5830
Practice Address - Country:US
Practice Address - Phone:714-994-0500
Practice Address - Fax:714-994-0515
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BETHANY CHRISTIAN SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC38441106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty