Provider Demographics
NPI:1790105732
Name:SAN GABRIEL VALLEY BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:SAN GABRIEL VALLEY BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:626-862-6535
Mailing Address - Street 1:324 WEST FOOTHILL BLVD.
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016
Mailing Address - Country:US
Mailing Address - Phone:626-862-6535
Mailing Address - Fax:209-253-1078
Practice Address - Street 1:324 WEST FOOTHILL BLVD.
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016
Practice Address - Country:US
Practice Address - Phone:626-862-6535
Practice Address - Fax:209-253-1078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-17
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health