Healthcare Provider Details

I. General information

NPI: 1467586214
Provider Name (Legal Business Name): BRIAN SCOTT PENDLEBERRY LPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1722 S LEWIS RD
CAMARILLO CA
93012-8520
US

IV. Provider business mailing address

307 CHARRO AVE
THOUSAND OAKS CA
91320-3658
US

V. Phone/Fax

Practice location:
  • Phone: 805-445-7800
  • Fax: 805-445-7830
Mailing address:
  • Phone: 805-630-3101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT24244
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: