Provider Demographics
NPI:1902034101
Name:LAUSD 97TH ST SMH CLINIC
Entity Type:Organization
Organization Name:LAUSD 97TH ST SMH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ESCUDERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-241-3841
Mailing Address - Street 1:333 S BEAUDRY AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1466
Mailing Address - Country:US
Mailing Address - Phone:213-241-3841
Mailing Address - Fax:213-241-3305
Practice Address - Street 1:439 W 97TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-3968
Practice Address - Country:US
Practice Address - Phone:323-754-2856
Practice Address - Fax:323-754-1843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X, 163WP0808X
CA03151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0315OtherLA CTY ENTITY