1780918102 NPI number — LAURA ADDISON DBA ADDISON BEHAVIORAL RESOURCES

Table of content: (NPI 1780918102)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780918102 NPI number — LAURA ADDISON DBA ADDISON BEHAVIORAL RESOURCES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAURA ADDISON DBA ADDISON BEHAVIORAL RESOURCES
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:
1780918102
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
266 MOBIL AVE
Provider Second Line Business Mailing Address:
SUITE 209
Provider Business Mailing Address City Name:
CAMARILLO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93010-6328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-383-5566
Provider Business Mailing Address Fax Number:
888-659-0031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
266 MOBIL AVE
Provider Second Line Business Practice Location Address:
SUITE 209
Provider Business Practice Location Address City Name:
CAMARILLO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93010-6328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-383-5566
Provider Business Practice Location Address Fax Number:
888-659-0031
Provider Enumeration Date:
10/01/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ADDISON
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
805-383-5566

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-05-2114 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 252Y00000X , with the licence number: PSY 22059 , 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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