1902016348 NPI number — PETRUS PSYCHOLOGY PROFESSIONAL CORPORATION

Table of content: (NPI 1902016348)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902016348 NPI number — PETRUS PSYCHOLOGY PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETRUS PSYCHOLOGY PROFESSIONAL CORPORATION
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:
Provider Other Organization Name Type Code:
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:
1902016348
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3625 E THOUSAND OAKS BLVD
Provider Second Line Business Mailing Address:
SUITE 135
Provider Business Mailing Address City Name:
WESTLAKE VILLAGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91362-3626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-496-6180
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3625 E THOUSAND OAKS BLVD
Provider Second Line Business Practice Location Address:
SUITE 135
Provider Business Practice Location Address City Name:
WESTLAKE VILLAGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91362-3626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-496-6180
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PETRUS
Authorized Official First Name:
GINA
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
805-496-6180

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY17390 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: PSY19903 , 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)