Healthcare Provider Details

I. General information

NPI: 1851839419
Provider Name (Legal Business Name): CASEY J. SIMON M.S., LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2017
Last Update Date: 10/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 BRIDGEGATE STREET SUITE #108
WESTLAKE VILLAGE CA
91361
US

IV. Provider business mailing address

1800 BRIDGEGATE STREET SUITE #108
WESTLAKE VILLAGE CA
91361
US

V. Phone/Fax

Practice location:
  • Phone: 805-402-9385
  • Fax:
Mailing address:
  • Phone: 805-402-9385
  • Fax: 805-267-9692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMFT97789
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMFT97789
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT97789
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberMFT97789
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: