Basic Information
| Provider Information | |||||||||
| NPI: | 1093272817 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMON | ||||||||
| FirstName: | EMMA | ||||||||
| MiddleName: | FAY | ||||||||
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| Credential: | ACSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 974 RANCH HOUSE RD | ||||||||
| Address2: | |||||||||
| City: | THOUSAND OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913612041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015568951 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4001 MISSION OAKS BLVD STE 1 | ||||||||
| Address2: | |||||||||
| City: | CAMARILLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930125121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054856114 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2019 | ||||||||
| LastUpdateDate: | 01/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 85240 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.