Healthcare Provider Details

I. General information

NPI: 1023937406
Provider Name (Legal Business Name): WHOLLY INTEGRATED MENTAL HEALTH FOR CHILDREN,ADOLESCENTS&YOUNG ADULTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 08/09/2026
Certification Date: 08/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 FIGUEROA ST STE 5
VENTURA CA
93001-2756
US

IV. Provider business mailing address

6818 GLADE AVE
CANOGA PARK CA
91303-2318
US

V. Phone/Fax

Practice location:
  • Phone: 818-746-8458
  • Fax:
Mailing address:
  • Phone: 805-798-4108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARYELLEN DYER-RUSSELL
Title or Position: OWNER OF NURSING CORPORTATION
Credential: DNP; PMHNP
Phone: 805-798-4108