Healthcare Provider Details

I. General information

NPI: 1841662772
Provider Name (Legal Business Name): SHANE P HUTTON PHD A PROFESSIONAL PSYCHOLOGIST CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2015
Last Update Date: 10/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9444 REVERIE RD
TUJUNGA CA
91042-3024
US

IV. Provider business mailing address

9444 REVERIE RD
TUJUNGA CA
91042-3024
US

V. Phone/Fax

Practice location:
  • Phone: 818-569-9440
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY23919
License Number StateCA

VIII. Authorized Official

Name: SHANE P HUTTON
Title or Position: PROVIDER/PRESIDENT
Credential:
Phone: 818-569-9440