=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992938278
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GERIATRIC EVALUATION & NEUROPSYCHOLOGICAL SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2009
-----------------------------------------------------
Last Update Date | 09/02/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15235 BURBANK BLVD A4
-----------------------------------------------------
City | VAN NUYS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91411-3500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-314-8088
-----------------------------------------------------
Fax | 818-708-8498
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18375 VENTURA BLVD 578
-----------------------------------------------------
City | TARZANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91356-4218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-314-8088
-----------------------------------------------------
Fax | 818-708-8498
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JENA AVITAL KRAVITZ
-----------------------------------------------------
Credential | PSY.D
-----------------------------------------------------
Telephone | 818-314-8088
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY21989
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------