Healthcare Provider Details

I. General information

NPI: 1548670797
Provider Name (Legal Business Name): SILVER OWL CONNECTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 04/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 S LAKE AVE SUITE 240
PASADENA CA
91101
US

IV. Provider business mailing address

202 S LAKE AVE STE 240
PASADENA CA
91101-4831
US

V. Phone/Fax

Practice location:
  • Phone: 626-319-6327
  • Fax:
Mailing address:
  • Phone: 626-319-6327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number22723
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number77636
License Number StateCA

VIII. Authorized Official

Name: DR. AUDREY HAM
Title or Position: PARTNER
Credential: PHD
Phone: 626-319-6327