Provider Demographics
NPI:1336861517
Name:THE THERAPEUTIC DOJO PSYCHOTHERAPY SERVICES A PROFESSIONAL LICENSED CL
Entity Type:Organization
Organization Name:THE THERAPEUTIC DOJO PSYCHOTHERAPY SERVICES A PROFESSIONAL LICENSED CL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TANICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TROTTER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:949-993-8604
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-0043
Mailing Address - Country:US
Mailing Address - Phone:949-993-8606
Mailing Address - Fax:
Practice Address - Street 1:1100 WILSHIRE BLVD APT 2210
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1951
Practice Address - Country:US
Practice Address - Phone:949-993-8606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI4765OtherSTATE OF HAWAII DEPT. OF COMMERCE AND CONSUMER AFFAIRS
CA21067OtherCALIFORNIA BOARD OF BEHAVIORAL SCIENCES
1275612657OtherNPI