Provider Demographics
NPI:1225452691
Name:MALIBU BEHAVIORAL HEALTH SERVICES, INC
Entity Type:Organization
Organization Name:MALIBU BEHAVIORAL HEALTH SERVICES, INC
Other - Org Name:'SOUTH CALIFORNIA ROAD TO RECOVERY'
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CASE MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:ANGELIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:PANOVA
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT, MS-RN
Authorized Official - Phone:714-887-3816
Mailing Address - Street 1:1057 E IMPERIAL HWY APT 226
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-1717
Mailing Address - Country:US
Mailing Address - Phone:951-215-0881
Mailing Address - Fax:951-215-0881
Practice Address - Street 1:7057 GASKIN PL
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-5615
Practice Address - Country:US
Practice Address - Phone:951-776-8869
Practice Address - Fax:951-215-0881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-06
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49586106H00000X
CA804708163WA0400X, 163WC0400X
CA330128AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)Group - Single Specialty
No163WC0400XNursing Service ProvidersRegistered NurseCase ManagementGroup - Single Specialty