Provider Demographics
NPI:1467961490
Name:MUTAFYAN, GEORGETTE
Entity Type:Individual
Prefix:
First Name:GEORGETTE
Middle Name:
Last Name:MUTAFYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14101 SADDLETREE CT
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-1062
Mailing Address - Country:US
Mailing Address - Phone:818-602-2723
Mailing Address - Fax:
Practice Address - Street 1:16500 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2011
Practice Address - Country:US
Practice Address - Phone:818-788-1003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician