Provider Demographics
NPI:1750368999
Name:UC REGENTS
Entity type:Organization
Organization Name:UC REGENTS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROF OF CLIN PSY CHAIR & DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:GITLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-825-9989
Mailing Address - Street 1:FILE 2939
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074
Mailing Address - Country:US
Mailing Address - Phone:310-825-9989
Mailing Address - Fax:
Practice Address - Street 1:300 MEDICAL PLAZA
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095
Practice Address - Country:US
Practice Address - Phone:310-825-9989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TC0700X, 103TC2200X, 235Z00000X, 103TA0700X
2084P0800X, 2084P0804X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGPS000090Medicaid
CAGR0053840Medicaid
CAGSP000650Medicaid
CAGSP000650Medicaid