Basic Information
Provider Information | |||||||||
NPI: | 1467586214 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PENDLEBERRY | ||||||||
FirstName: | BRIAN | ||||||||
MiddleName: | SCOTT | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 307 CHARRO AVE | ||||||||
Address2: |   | ||||||||
City: | THOUSAND OAKS | ||||||||
State: | CA | ||||||||
PostalCode: | 913203658 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056303101 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1722 S LEWIS RD | ||||||||
Address2: |   | ||||||||
City: | CAMARILLO | ||||||||
State: | CA | ||||||||
PostalCode: | 930128520 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8054457800 | ||||||||
FaxNumber: | 8054457830 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/15/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | PT24244 | CA | Y |   | Nursing Service Providers | Licensed Psychiatric Technician |   |
ID Information
ID | Type | State | Issuer | Description | PT24244 | 01 | CA | LICENSE | OTHER |