Provider Demographics
NPI:1316025240
Name:FRIEL, JOHN CHARLES (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHARLES
Last Name:FRIEL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 SUNNY VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91377-1013
Mailing Address - Country:US
Mailing Address - Phone:310-422-8233
Mailing Address - Fax:
Practice Address - Street 1:401 SAN VICENTE BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90402-1744
Practice Address - Country:US
Practice Address - Phone:310-422-8233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00377600103G00000X
CAPSY 17493103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9090002Medicaid
NJ045588CBHMedicare ID - Type Unspecified
NJP24954Medicare UPIN