Provider Demographics
NPI:1285874255
Name:PHILLIPS GRADUATE UNIVERSITY
Entity type:Organization
Organization Name:PHILLIPS GRADUATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTOPHER
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:818-386-5612
Mailing Address - Street 1:19900 PLUMMER STREET
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311
Mailing Address - Country:US
Mailing Address - Phone:818-907-9980
Mailing Address - Fax:818-386-5694
Practice Address - Street 1:19900 PLUMMER ST
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-5541
Practice Address - Country:US
Practice Address - Phone:818-907-9980
Practice Address - Fax:818-386-5694
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHILLIPS GRADUATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)