Basic Information
Provider Information | |||||||||
NPI: | 1972768695 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAN FERNANDO VALLEY COMMUNITY MENTAL HEALTH CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SFVCMHC JUV JUST BJN SAT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 16350 FILBERT ST | ||||||||
Address2: |   | ||||||||
City: | SYLMAR | ||||||||
State: | CA | ||||||||
PostalCode: | 913421002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8189014879 | ||||||||
FaxNumber: | 8189971370 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/22/2008 | ||||||||
LastUpdateDate: | 04/06/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RYDER | ||||||||
AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8189014830 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/06/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 00007622 | 01 | CA | MEDICAL PROVIDER | OTHER |