Basic Information
Provider Information | |||||||||
NPI: | 1326484296 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WEST VALLEY COUNSELING CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 19634 VENTURA BLVD | ||||||||
Address2: | SUITE 212 | ||||||||
City: | TARZANA | ||||||||
State: | CA | ||||||||
PostalCode: | 913562966 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8187589450 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 19634 VENTURA BLVD | ||||||||
Address2: | SUITE 212 | ||||||||
City: | TARZANA | ||||||||
State: | CA | ||||||||
PostalCode: | 913562966 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8187589450 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2013 | ||||||||
LastUpdateDate: | 05/17/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BURNETT | ||||||||
AuthorizedOfficialFirstName: | SHARON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR CLINICAL SUPERVI | ||||||||
AuthorizedOfficialTelephone: | 8187589450 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MFT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFT16203 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
No ID Information.