NPIMap

Organization Active NPI

Pacific Blue Psychological Services

  • Psychologist
  • Sherman Oaks, CA
National Provider Identifier
1124678719
Registry record updated Oct 9, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
PsychologistTaxonomy code 103T00000X
Legal business name
PACIFIC BLUE PSYCHOLOGICAL SERVICES
Practice address
15235 Burbank Blvd Ste A2
Sherman Oaks, CA 91411-3555
Phone
(858) 883-3277
NPI assigned
Sep 16, 2019
Last updated
Oct 9, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 9, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
John Carroll, PSYDNPI 1972002236
Title
Owner
Phone
(858) 883-3277

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
PsychologistGroup: 193400000X SINGLE SPECIALTY GROUP 103T00000X Primary

Addresses

Primary practice location

15235 Burbank Blvd Ste A2
Sherman Oaks, CA 91411-3555

Mailing address

PO Box 1290
Venice, CA 90294-1290

Other practice location 1

4133 Redwood Ave Unit 1002
Los Angeles, CA 90066-5627
Phone (858) 883-3277

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200129000198 CA Part B Supplier - Clinic/Group Practice 3678908357 Receives reassigned benefits from 26 practitioners
Practice locations: Sherman Oaks, CA

National Provider Directory

National Provider Directory

Locations

3570 E Imperial Hwy
Lynwood, CA 90262
Phone (858) 883-3277

15235 Burbank Blvd
Ste A2
Van Nuys, CA 91411
Phone (949) 504-1963

Practitioners & affiliated clinicians

Practitioners 26

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 26

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1568592000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1602201600000",
    "number": "1124678719",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1290",
            "city": "VENICE",
            "state": "CA",
            "postal_code": "902941290"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "15235 BURBANK BLVD STE A2",
            "city": "SHERMAN OAKS",
            "state": "CA",
            "postal_code": "914113555",
            "telephone_number": "858-883-3277"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "4133 Redwood Ave Unit 1002",
            "address_purpose": "LOCATION",
            "city": "Los Angeles",
            "state": "CA",
            "postal_code": "900665627",
            "country_code": "US",
            "telephone_number": "858-883-3277",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "PACIFIC BLUE PSYCHOLOGICAL SERVICES",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-09-16",
        "last_updated": "2020-10-09",
        "certification_date": "2020-10-09",
        "status": "A",
        "authorized_official_last_name": "CARROLL",
        "authorized_official_first_name": "JOHN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "858-883-3277",
        "authorized_official_credential": "PSYD"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Psychologist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Sherman Oaks, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 9, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.