Provider Demographics
NPI:1922419548
Name:SILVER LAKE PSYCHOTHERAPY PC
Entity Type:Organization
Organization Name:SILVER LAKE PSYCHOTHERAPY PC
Other - Org Name:SILVER LAKE PSYCHOTHERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-244-2066
Mailing Address - Street 1:1934 HILLHURST AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-2712
Mailing Address - Country:US
Mailing Address - Phone:323-244-2066
Mailing Address - Fax:323-275-0952
Practice Address - Street 1:1934 HILLHURST AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-2712
Practice Address - Country:US
Practice Address - Phone:323-244-2066
Practice Address - Fax:323-275-0952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-16
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 102L00000X, 103T00000X, 1041C0700X, 106H00000X, 261QM0850X
CAPSY-23766251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1952829418OtherALISON DAVIES
CA1952829418OtherALISON DAVIES
CA1871929059OtherSOPHIE DAVIS-COHEN