MEDICARE: SAN FERNANDO VALLEY COMMUNITY MENTAL HEALTH CENTER, 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	2084P0800X	Psychiatry Physician	D0591483	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000007177	OTHER	CA	MEDICAL PROVIDER

General Provider Information

NPI Number	:	1912037060
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN FERNANDO VALLEY COMMUNITY MENTAL HEALTH CENTER, INC.

Provider Business Mailing Address
First Line	:	16360 ROSCOE BLVD
Second Line	:	SUITE 200
City	:	VAN NUYS
State	:	CA
Zip	:	91406-1219
Country	:	US
Telephone Number	:	818-901-4830
Fax Number	:	818-785-3446

Provider Business Practice Location Address
First Line	:	11631 VICTORY BLVD
Second Line	:	#203
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91606-3572
Country	:	US
Telephone Number	:	818-908-3855
Fax Number	:	818-753-5265

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TIMOTHY RYDER
Credential	:
Telephone Number	:	818-901-4830

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	04/07/2021

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Directions to “SAN FERNANDO VALLEY COMMUNITY MENTAL HEALTH CENTER, INC. ” Practice Location

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