Healthcare Provider Details

I. General information

NPI: 1144698564
Provider Name (Legal Business Name): CALIFORNIA STATE UNIVERSITY NORTHRIDGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2015
Last Update Date: 09/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 W AVENUE I
LANCASTER CA
93536-8312
US

IV. Provider business mailing address

18111 NORDHOFF ST
NORTHRIDGE CA
91330-8226
US

V. Phone/Fax

Practice location:
  • Phone: 661-940-4122
  • Fax:
Mailing address:
  • Phone: 818-677-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MISS TIFFANY BROOKS
Title or Position: FIELD CONSULTANT LIAISON SW DEPT
Credential: LCSW
Phone: 310-351-1809