Provider Demographics
NPI:1326173584
Name:MID VALLEY YOUTH CENTER
Entity Type:Organization
Organization Name:MID VALLEY YOUTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ANGELIKI
Authorized Official - Middle Name:
Authorized Official - Last Name:ECONOMOU
Authorized Official - Suffix:
Authorized Official - Credentials:MFTI
Authorized Official - Phone:818-904-0707
Mailing Address - Street 1:15446 SHERMAN WAY
Mailing Address - Street 2:330
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-4259
Mailing Address - Country:US
Mailing Address - Phone:818-988-6544
Mailing Address - Fax:
Practice Address - Street 1:15446 SHERMAN WAY
Practice Address - Street 2:330
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-4259
Practice Address - Country:US
Practice Address - Phone:818-988-6544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37870322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01345207Medicare ID - Type UnspecifiedRESIDENTIAL TREATMENT FAC