Provider Demographics
NPI:1205140548
Name:PEDIATRIC MINDS MEDICAL CENTER
Entity type:Organization
Organization Name:PEDIATRIC MINDS MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:APODACA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-206-1919
Mailing Address - Street 1:3524 TORRANCE BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-4821
Mailing Address - Country:US
Mailing Address - Phone:310-540-1630
Mailing Address - Fax:310-543-0400
Practice Address - Street 1:3524 TORRANCE BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4821
Practice Address - Country:US
Practice Address - Phone:310-540-1630
Practice Address - Fax:310-543-0400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-28
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X, 103G00000X, 103TM1800X, 103TP2701X
CAA78624261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty