1467969071 NPI number — FAMILY MODEL BEHAVIOR THERAPY

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 1467969071 NPI number — FAMILY MODEL BEHAVIOR THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY MODEL BEHAVIOR THERAPY
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:
6
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:
1467969071
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18802 MANDAN STREET
Provider Second Line Business Mailing Address:
#901
Provider Business Mailing Address City Name:
CANYON COUNTRY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91351-3763
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-261-5580
Provider Business Mailing Address Fax Number:
661-367-7778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18802 MANDAN STREET
Provider Second Line Business Practice Location Address:
#901
Provider Business Practice Location Address City Name:
CANYON COUNTRY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91351-3763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-261-5580
Provider Business Practice Location Address Fax Number:
661-367-7778
Provider Enumeration Date:
01/04/2018

Additional Information

Authorized Official

Authorized Official Last Name:
HART
Authorized Official First Name:
KEEGAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
818-261-5580

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-15-18352 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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