Healthcare Provider Details

I. General information

NPI: 1114300597
Provider Name (Legal Business Name): PLATINUM BEHAVIORAL MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2015
Last Update Date: 07/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18003 FLYNN DR UNIT 542
CANYON COUNTRY CA
91387-4919
US

IV. Provider business mailing address

18003 FLYNN DR UNIT 542
CANYON COUNTRY CA
91387-4919
US

V. Phone/Fax

Practice location:
  • Phone: 661-992-3610
  • Fax:
Mailing address:
  • Phone: 661-992-3610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1-12-11854
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number1-12-11854
License Number StateCA

VIII. Authorized Official

Name: KIMBERLY MICHELLE BENJAMIN
Title or Position: CO OWNER
Credential: BCBA
Phone: 661-992-3610