Provider Demographics
NPI:1124588025
Name:SCULLY, PHILIP JAMES
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:JAMES
Last Name:SCULLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6480 KATHERINE RD SPC 10
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-6454
Mailing Address - Country:US
Mailing Address - Phone:805-428-5304
Mailing Address - Fax:
Practice Address - Street 1:2625 TOWNSGATE RD STE 102
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-5726
Practice Address - Country:US
Practice Address - Phone:818-285-8252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-19-35332103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1-19-35332OtherBACB