Healthcare Provider Details

I. General information

NPI: 1225452691
Provider Name (Legal Business Name): MALIBU BEHAVIORAL HEALTH SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 09/05/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7057 GASKIN PL
RIVERSIDE CA
92506-5615
US

IV. Provider business mailing address

1057 E IMPERIAL HWY APT 226
PLACENTIA CA
92870-1717
US

V. Phone/Fax

Practice location:
  • Phone: 951-776-8869
  • Fax: 951-215-0881
Mailing address:
  • Phone: 951-215-0881
  • Fax: 951-215-0881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number49586
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number804708
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number804708
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number330128AP
License Number StateCA

VIII. Authorized Official

Name: ANGELIKA PANOVA
Title or Position: EXECUTIVE MANAGER
Credential: PMHNP-RN, LMFT
Phone: 714-887-3816