Basic Information
Provider Information | |||||||||
NPI: | 1922387661 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KELVIN | ||||||||
FirstName: | CYNTHIA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HOLLOWAY | ||||||||
OtherFirstName: | CYNTHIA | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5242 KESTER AVE APT 8 | ||||||||
Address2: |   | ||||||||
City: | SHERMAN OAKS | ||||||||
State: | CA | ||||||||
PostalCode: | 914114085 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8182779815 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6842 VAN NUYS BLVD | ||||||||
Address2: | 6TH FLOOR | ||||||||
City: | VAN NUYS | ||||||||
State: | CA | ||||||||
PostalCode: | 914054650 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8189014830 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/12/2011 | ||||||||
LastUpdateDate: | 12/07/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X |   |   | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |   | 103TC0700X | 2012665 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.