Provider Demographics
NPI:1992018469
Name:BEACHSIDE ADULT AND FAMILY THERAPY INC
Entity Type:Organization
Organization Name:BEACHSIDE ADULT AND FAMILY THERAPY INC
Other - Org Name:BEACHSIDE THERAPY AND ASSESSMENT CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:O'REILLY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LMFT
Authorized Official - Phone:805-642-4611
Mailing Address - Street 1:3160 TELEGRAPH RD STE 200
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-3250
Mailing Address - Country:US
Mailing Address - Phone:805-642-4611
Mailing Address - Fax:805-585-3241
Practice Address - Street 1:3160 TELEGRAPH RD STE 200
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3250
Practice Address - Country:US
Practice Address - Phone:805-642-4611
Practice Address - Fax:805-585-3241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-26
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1241840OtherBEACON
CA700687251Medicaid