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General NPI Number Information
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NPI Number | 1699019786
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Entity Type | Organization
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Legal Business Name | SELF
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Dates
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Enumeration Date | 11/15/2012
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Last Update Date | 11/15/2012
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Provider Practice Location Address
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Address Line | 10136 AMIGO AVE
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City | NORTHRIDGE
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State | CA
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Zip | 91324-1301
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Country | US
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Telephone | 818-263-7904
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Fax |
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Provider Business Mailing Address
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Address Line | 10136 AMIGO AVE
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City | NORTHRIDGE
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State | CA
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Zip | 91324-1301
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | LCSW
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Name | MARIA NIEVES ORNELAS
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Credential |
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Telephone | 818-263-7904
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | LCS 20834
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License Number State | CA
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