Healthcare Provider Details

I. General information

NPI: 1922419548
Provider Name (Legal Business Name): SILVER LAKE PSYCHOTHERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2014
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1934 HILLHURST AVE
LOS ANGELES CA
90027-2712
US

IV. Provider business mailing address

1934 HILLHURST AVE
LOS ANGELES CA
90027-2712
US

V. Phone/Fax

Practice location:
  • Phone: 323-244-2066
  • Fax: 323-275-0952
Mailing address:
  • Phone: 323-244-2066
  • Fax: 323-275-0952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberPSY-23766
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN SHUBERT
Title or Position: PSYCHOLOGIST
Credential:
Phone: 323-244-2066