Healthcare Provider Details

I. General information

NPI: 1104318757
Provider Name (Legal Business Name): CASEY RAY PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 10/07/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19360 RINALDI ST # 441
PORTER RANCH CA
91326-1607
US

IV. Provider business mailing address

19360 RINALDI ST. #441
CHATSWORTH CA
91311
US

V. Phone/Fax

Practice location:
  • Phone: 818-208-1501
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95033737
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95134981
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: