Provider Demographics
NPI:1457797953
Name:PACIFIC TRAUMA TREATMENT CENTER
Entity Type:Organization
Organization Name:PACIFIC TRAUMA TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:GIANA
Authorized Official - Last Name:WOODS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:310-738-4232
Mailing Address - Street 1:PO BOX 81184
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91118-1184
Mailing Address - Country:US
Mailing Address - Phone:310-738-4232
Mailing Address - Fax:
Practice Address - Street 1:444 S MARENGO AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-3113
Practice Address - Country:US
Practice Address - Phone:310-738-4232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-11
Last Update Date:2013-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC46170106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty