Provider Demographics
NPI:1457643652
Name:MCRORY PEDIATRIC SERVICES
Entity Type:Organization
Organization Name:MCRORY PEDIATRIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ABA PROGRAM THERAPY SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:LIANE
Authorized Official - Last Name:BEDRE
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:818-635-2250
Mailing Address - Street 1:17609 VENTURA BLVD
Mailing Address - Street 2:SUITE # 215
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3858
Mailing Address - Country:US
Mailing Address - Phone:818-501-8352
Mailing Address - Fax:818-501-8325
Practice Address - Street 1:17609 VENTURA BLVD
Practice Address - Street 2:SUITE # 215
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-3858
Practice Address - Country:US
Practice Address - Phone:818-501-8352
Practice Address - Fax:818-501-8325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-05
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-11-8354103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty