05D2275959 CLIA NUMBER - NEWPORT ACADEMY - SANTA MONICA

Laboratory Demographics

CLIA Number: 05D2275959

Facility Name: NEWPORT ACADEMY - SANTA MONICA

Facility Address:
2001 WILSHIRE BLVD SUITE 525
SANTA MONICA, CA
ZIP 90403
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Facility Phone Number: 714 393-3523

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1073109047

Taxonomy: 261QM0855X - Clinic/Center
An entity, facility, or distinct part of a facility providing diagnostic, treatment, and prescriptive services related to mental and behavioral disorders in children and adolescents. Services may be provided to parents and family members of the patient in the form of conjoint, group, or individual therapy, and education and/or training.

CLIA Record

Field Name	Field Value
CLIA Number	05D2275959
LAB Type	Practitioner Other
Facility Name	NEWPORT ACADEMY - SANTA MONICA
Street	2001 WILSHIRE BLVD SUITE 525
City	SANTA MONICA
State	CA
ZIP	90403
Phone	714 393-3523
CertificateType	4
CertificateEffectiveDate	1/31/2023
CertificateExpirationDate	1/30/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024