Provider Demographics
NPI:1841492212
Name:KAISER PERMANENTE
Entity type:Organization
Organization Name:KAISER PERMANENTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:SELFA
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:323-298-3175
Mailing Address - Street 1:4440 DENSMORE AVE
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-3461
Mailing Address - Country:US
Mailing Address - Phone:818-788-9489
Mailing Address - Fax:
Practice Address - Street 1:5105 W GOLDLEAF CIR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90056-1269
Practice Address - Country:US
Practice Address - Phone:323-298-3175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC29709261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Not Answered261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health