Provider Demographics
NPI:1417378704
Name:EDUCATIONAL AND DEVELOPMENTAL THERAPIES
Entity type:Organization
Organization Name:EDUCATIONAL AND DEVELOPMENTAL THERAPIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MAXWELL
Authorized Official - Middle Name:RANEY
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-450-8004
Mailing Address - Street 1:2249 20TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-1742
Mailing Address - Country:US
Mailing Address - Phone:310-450-8004
Mailing Address - Fax:310-450-8004
Practice Address - Street 1:2249 20TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-1742
Practice Address - Country:US
Practice Address - Phone:310-450-8004
Practice Address - Fax:310-450-8004
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDI & DATABASE TECHNOLOGIES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-03
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA093343101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty