Provider Demographics
NPI:1629256524
Name:ANTELOPE VALLEY MENTAL HEALTH CLINIC
Entity Type:Organization
Organization Name:ANTELOPE VALLEY MENTAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM HEAD
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:JR
Authorized Official - Credentials:LCSW
Authorized Official - Phone:661-723-4260
Mailing Address - Street 1:349 E AVENUE K6 STE A
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-4548
Mailing Address - Country:US
Mailing Address - Phone:661-723-4260
Mailing Address - Fax:661-723-6975
Practice Address - Street 1:349 E AVENUE K6 STE A
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-4548
Practice Address - Country:US
Practice Address - Phone:661-723-4260
Practice Address - Fax:661-723-6975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC29538106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty