Provider Demographics
NPI:1790008258
Name:DEPARTMENT OF MENTAL HEALTH, LA COUNTY
Entity type:Organization
Organization Name:DEPARTMENT OF MENTAL HEALTH, LA COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF MENTAL HEALTH
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHARD
Authorized Official - Suffix:
Authorized Official - Credentials:DSW
Authorized Official - Phone:213-430-6700
Mailing Address - Street 1:4067 W. 3RD ST
Mailing Address - Street 2:#106
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020
Mailing Address - Country:US
Mailing Address - Phone:213-807-4639
Mailing Address - Fax:
Practice Address - Street 1:4067 W 3RD ST APT 106
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-3168
Practice Address - Country:US
Practice Address - Phone:213-807-4639
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD05195986251E00000X
WAMANTELA352PR305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD05195986OtherARIZONA IDENTIFICATION CARD