Provider Demographics
NPI:1558683201
Name:BUYLE, JON MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:MICHAEL
Last Name:BUYLE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 FAIR OAKS AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-2694
Mailing Address - Country:US
Mailing Address - Phone:323-341-5580
Mailing Address - Fax:323-340-8298
Practice Address - Street 1:1111 W 6TH ST STE 111
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1823
Practice Address - Country:US
Practice Address - Phone:323-404-1027
Practice Address - Fax:323-340-8298
Is Sole Proprietor?:No
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301001760103TC2200X
MI235724103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool