Basic Information
| Provider Information | |||||||||
| NPI: | 1346336286 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIMON | ||||||||
| FirstName: | BETH | ||||||||
| MiddleName: | VICTORIA | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6430 W SUNSET BLVD | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900287901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236692337 | ||||||||
| FaxNumber: | 3236448488 | ||||||||
| Practice Location | |||||||||
| Address1: | 4650 W SUNSET BLVD | ||||||||
| Address2: | MS# 76 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900276062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236692384 | ||||||||
| FaxNumber: | 3236711502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | PSY16328 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | PSY163280 | 05 | CA | MEDICAID |