Provider Demographics
NPI:1912390907
Name:PAIN PSYCHOLOGY CENTER: A LICENSED CLINICAL SOCIAL WORKER PC
Entity Type:Organization
Organization Name:PAIN PSYCHOLOGY CENTER: A LICENSED CLINICAL SOCIAL WORKER PC
Other - Org Name:PAIN PSYCHOLOGY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:310-853-2049
Mailing Address - Street 1:9777 WILSHIRE BLVD STE 1007
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-1901
Mailing Address - Country:US
Mailing Address - Phone:310-853-2049
Mailing Address - Fax:
Practice Address - Street 1:9777 WILSHIRE BLVD STE 1007
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-1901
Practice Address - Country:US
Practice Address - Phone:310-853-2049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-15
Last Update Date:2015-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health