Provider Demographics
NPI:1710233705
Name:CHILD COUNSELING & BEHAVIOR THERAPY CLINIC
Entity Type:Organization
Organization Name:CHILD COUNSELING & BEHAVIOR THERAPY CLINIC
Other - Org Name:BEHAVIOR THERAPY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:TASHJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MFT, BCBA
Authorized Official - Phone:818-788-2388
Mailing Address - Street 1:15720 VENTURA BLVD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2914
Mailing Address - Country:US
Mailing Address - Phone:818-788-2388
Mailing Address - Fax:818-788-3875
Practice Address - Street 1:15720 VENTURA BLVD
Practice Address - Street 2:SUITE 403
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2914
Practice Address - Country:US
Practice Address - Phone:818-788-2388
Practice Address - Fax:818-788-3875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-27
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC30490251S00000X
CABCBA # 1-10-7653251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health