Basic Information
Provider Information | |||||||||
NPI: | 1013047422 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAN FERNANDO VALLEY COMMUNITY MENTAL HEALTH CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SFVCMHC EVYFC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 16360 ROSCOE BLVD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | VAN NUYS | ||||||||
State: | CA | ||||||||
PostalCode: | 914061219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8189014830 | ||||||||
FaxNumber: | 8187853446 | ||||||||
Practice Location | |||||||||
Address1: | 6400 LAUREL CANYON BLVD | ||||||||
Address2: | SUITE 500 | ||||||||
City: | NORTH HOLLYWOOD | ||||||||
State: | CA | ||||||||
PostalCode: | 916061571 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8189016376 | ||||||||
FaxNumber: | 8189049273 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/06/2007 | ||||||||
LastUpdateDate: | 02/04/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RYDER | ||||||||
AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8189014830 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/04/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 000006853 | 01 | CA | MEDICAL PROVIDER | OTHER |