Provider Demographics
NPI:1831748581
Name:ADVANCED PEDIATRIC BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:ADVANCED PEDIATRIC BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:818-646-9229
Mailing Address - Street 1:10442 YOLANDA AVE
Mailing Address - Street 2:
Mailing Address - City:PORTER RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91326-3440
Mailing Address - Country:US
Mailing Address - Phone:818-646-9229
Mailing Address - Fax:
Practice Address - Street 1:10442 YOLANDA AVE
Practice Address - Street 2:
Practice Address - City:PORTER RANCH
Practice Address - State:CA
Practice Address - Zip Code:91326-3440
Practice Address - Country:US
Practice Address - Phone:818-606-3754
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-05
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service