Provider Demographics
NPI:1912037797
Name:BEHAVIORAL HEALTH SERVICES
Entity Type:Organization
Organization Name:BEHAVIORAL HEALTH SERVICES
Other - Org Name:INGLEWOOD COMMUNITY RECOVERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:TERI
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-679-9126
Mailing Address - Street 1:15519 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-4525
Mailing Address - Country:US
Mailing Address - Phone:310-679-9126
Mailing Address - Fax:310-679-2920
Practice Address - Street 1:404 EDGEWOOD ST
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90302-3415
Practice Address - Country:US
Practice Address - Phone:310-673-5750
Practice Address - Fax:310-673-1236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190007BN251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA190007BNOtherALCOHOL DRUG CERTIFICATIO