Provider Demographics
NPI:1962819789
Name:PSYCHIATRIC WELLNESS CENTER INC
Entity Type:Organization
Organization Name:PSYCHIATRIC WELLNESS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELSA
Authorized Official - Middle Name:CALUMPIT
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-795-2515
Mailing Address - Street 1:30300 AGOURA ROAD
Mailing Address - Street 2:SUITE 195
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-5412
Mailing Address - Country:US
Mailing Address - Phone:818-532-7950
Mailing Address - Fax:818-532-7685
Practice Address - Street 1:30300 AGOURA ROAD
Practice Address - Street 2:SUITE 195
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-5412
Practice Address - Country:US
Practice Address - Phone:818-532-7950
Practice Address - Fax:818-532-7685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC0700X
CAA757572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty