Provider Demographics
NPI:1194896498
Name:SPORTS CONCUSSION INSTITUTE A PSYCHOLOGY GROUP INC
Entity type:Organization
Organization Name:SPORTS CONCUSSION INSTITUTE A PSYCHOLOGY GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:L
Authorized Official - Last Name:STRICKLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:310-643-9595
Mailing Address - Street 1:5230 PACIFIC CONCOURSE DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-6200
Mailing Address - Country:US
Mailing Address - Phone:310-643-9595
Mailing Address - Fax:310-643-5180
Practice Address - Street 1:5230 PACIFIC CONCOURSE DR
Practice Address - Street 2:SUITE 300
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-6200
Practice Address - Country:US
Practice Address - Phone:310-643-9595
Practice Address - Fax:310-643-5180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12223103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ50434YOtherBLUE SHIELD
CAW21403Medicare PIN