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General NPI Number Information
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NPI Number | 1841662772
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Entity Type | Organization
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Legal Business Name | SHANE P HUTTON PHD A PROFESSIONAL PSYCHOLOGIST CORPORATION
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Dates
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Enumeration Date | 10/30/2015
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Last Update Date | 10/30/2015
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Provider Practice Location Address
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Address Line | 9444 REVERIE RD
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City | TUJUNGA
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State | CA
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Zip | 91042-3024
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Country | US
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Telephone | 818-569-9440
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Fax |
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Provider Business Mailing Address
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Address Line | 9444 REVERIE RD
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City | TUJUNGA
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State | CA
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Zip | 91042-3024
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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 | PROVIDER/PRESIDENT
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Name | SHANE P HUTTON
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Credential |
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Telephone | 818-569-9440
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY23919
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License Number State | CA
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