Healthcare Provider Details

I. General information

NPI: 1851240378
Provider Name (Legal Business Name): SUMMIT INTENSIVE OUTPATIENT PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21115 VANOWEN ST # 110
CANOGA PARK CA
91303-2849
US

IV. Provider business mailing address

21115 VANOWEN ST # 110
CANOGA PARK CA
91303-2849
US

V. Phone/Fax

Practice location:
  • Phone: 888-885-6648
  • Fax:
Mailing address:
  • Phone: 888-885-6648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: VYACHESLAV DAVTIAN
Title or Position: CEO
Credential:
Phone: 888-885-6648