MEDICARE: LIFESPAN: A CENTER FOR FAMILY PSYCHOLOGICAL SERVICES INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1255096426
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESPAN: A CENTER FOR FAMILY PSYCHOLOGICAL SERVICES INC.

Provider Business Mailing Address
First Line	:	964 EL SEGUNDO DR
Second Line	:
City	:	THOUSAND OAKS
State	:	CA
Zip	:	91362-2201
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2801 TOWNSGATE RD STE 133
Second Line	:
City	:	THOUSAND OAKS
State	:	CA
Zip	:	91361-5834
Country	:	US
Telephone Number	:	805-852-5039
Fax Number	:	818-279-0585

Authorized Official
Title or Position	:	CFO
Name	:	MR. EDMON ARTINYAN
Credential	:	PSYD
Telephone Number	:	805-852-5039

Provider Enumeration Date	:	11/03/2021
Last Update Date	:	12/07/2022

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