1710233705 NPI number — CHILD COUNSELING & BEHAVIOR THERAPY CLINIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710233705 NPI number — CHILD COUNSELING & BEHAVIOR THERAPY CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILD COUNSELING & BEHAVIOR THERAPY CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BEHAVIOR THERAPY CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710233705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15720 VENTURA BLVD
Provider Second Line Business Mailing Address:
SUITE 403
Provider Business Mailing Address City Name:
ENCINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91436-2914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-788-2388
Provider Business Mailing Address Fax Number:
818-788-3875

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15720 VENTURA BLVD
Provider Second Line Business Practice Location Address:
SUITE 403
Provider Business Practice Location Address City Name:
ENCINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91436-2914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-788-2388
Provider Business Practice Location Address Fax Number:
818-788-3875
Provider Enumeration Date:
07/27/2012

Additional Information

Authorized Official

Authorized Official Last Name:
TASHJIAN
Authorized Official First Name:
WAYNE
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
818-788-2388

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  MFC30490 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251S00000X , with the licence number: BCBA # 1-10-7653 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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