Provider Demographics
NPI:1306084272
Name:JAIME ELIZABETH MEDVENE PHD A PROFESSIONAL PSYCHOLOGICAL CORPORA
Entity type:Organization
Organization Name:JAIME ELIZABETH MEDVENE PHD A PROFESSIONAL PSYCHOLOGICAL CORPORA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:MEDVENE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:818-981-7845
Mailing Address - Street 1:30200 AGOURA RD
Mailing Address - Street 2:SUITE 190
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-5434
Mailing Address - Country:US
Mailing Address - Phone:818-981-7845
Mailing Address - Fax:
Practice Address - Street 1:30200 AGOURA RD
Practice Address - Street 2:SUITE 190
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-5434
Practice Address - Country:US
Practice Address - Phone:818-981-7845
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-30
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACP13740103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY137401Medicaid
BK964Medicare PIN