Provider Demographics
NPI:1083733745
Name:THE REGENTS OF THE UNIVERSITY OF CALIFORNIA
Entity type:Organization
Organization Name:THE REGENTS OF THE UNIVERSITY OF CALIFORNIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AUDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:LANGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:310-794-2460
Mailing Address - Street 1:1000 VETERAN AVE
Mailing Address - Street 2:714222
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-7142
Mailing Address - Country:US
Mailing Address - Phone:310-825-6110
Mailing Address - Fax:310-794-4996
Practice Address - Street 1:1000 VETERAN AVE BX 714222
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-7142
Practice Address - Country:US
Practice Address - Phone:310-825-6110
Practice Address - Fax:310-794-4996
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE REGENTS OF THE UNIVERSITY OF CALIFORNIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-27
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000007446Medicaid