Provider Demographics
NPI:1770975914
Name:SO. CAL. CHILD THERAPY
Entity type:Organization
Organization Name:SO. CAL. CHILD THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:JAKUBANIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:818-804-0322
Mailing Address - Street 1:6320 CANOGA AVE
Mailing Address - Street 2:15TH FLOOR
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-2526
Mailing Address - Country:US
Mailing Address - Phone:818-804-0322
Mailing Address - Fax:
Practice Address - Street 1:6320 CANOGA AVE
Practice Address - Street 2:15TH FLOOR
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-2526
Practice Address - Country:US
Practice Address - Phone:818-804-0322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 282341041S0200X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1700079191OtherINDIVIDUAL NPI NUMBER