Healthcare Provider Details

I. General information

NPI: 1801751615
Provider Name (Legal Business Name): PACIFICA BRAIN HEALTH RESIDENCY PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2025
Last Update Date: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14541 DELANO ST
VAN NUYS CA
91411-2820
US

IV. Provider business mailing address

18430 BROOKHURST ST STE 202E
FOUNTAIN VLY CA
92708-6762
US

V. Phone/Fax

Practice location:
  • Phone: 310-597-2081
  • Fax:
Mailing address:
  • Phone: 310-597-2081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. EKRAM YACOUB
Title or Position: CEO
Credential:
Phone: 310-597-2081