Healthcare Provider Details

I. General information

NPI: 1558683201
Provider Name (Legal Business Name): JON MICHAEL BUYLE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2010
Last Update Date: 02/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W 6TH ST STE 111
LOS ANGELES CA
90017-1823
US

IV. Provider business mailing address

625 FAIR OAKS AVE STE 200
SOUTH PASADENA CA
91030-2694
US

V. Phone/Fax

Practice location:
  • Phone: 323-404-1027
  • Fax: 323-340-8298
Mailing address:
  • Phone: 323-341-5580
  • Fax: 323-340-8298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6301001760
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number235724
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: