Basic Information
| Provider Information | |||||||||
| NPI: | 1538299680 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN FERNANDO VALLEY COMMUNITY MENTAL HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SFVCMHC INDEPENDENT LIVING PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 6501 VAN NUYS BLVD | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914011425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183745383 | ||||||||
| FaxNumber: | 8183745388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 10/23/2013 | ||||||||
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| AuthorizedOfficialLastName: | HUNTER | ||||||||
| AuthorizedOfficialFirstName: | IAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8189014830 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | D0591483 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 000007321 | 01 | CA | MEDICAL PROVIDER | OTHER |