Provider Demographics
NPI:1326701186
Name:CA MENTOR
Entity Type:Organization
Organization Name:CA MENTOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHILD & FAMILY SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-987-7144
Mailing Address - Street 1:761 WARRENDALE ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-7050
Mailing Address - Country:US
Mailing Address - Phone:818-987-7144
Mailing Address - Fax:
Practice Address - Street 1:10200 SEPULVEDA BLVD STE 170
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-3322
Practice Address - Country:US
Practice Address - Phone:818-895-9707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-19
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty