Provider Demographics
NPI:1588341689
Name:PSYCHEDELIC MEDICAL ASSOCIATES PC
Entity type:Organization
Organization Name:PSYCHEDELIC MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:HEINZERLING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-393-7129
Mailing Address - Street 1:1247 7TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-1644
Mailing Address - Country:US
Mailing Address - Phone:310-393-7129
Mailing Address - Fax:310-564-7839
Practice Address - Street 1:1247 7TH ST STE 300
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1644
Practice Address - Country:US
Practice Address - Phone:310-393-7129
Practice Address - Fax:310-564-7839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty