Provider Demographics
NPI:1922120088
Name:DAVE HALLBAUER
Entity type:Organization
Organization Name:DAVE HALLBAUER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:805-582-7507
Mailing Address - Street 1:3855 ALAMO ST STE F
Mailing Address - Street 2:SUITE 2032
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-2110
Mailing Address - Country:US
Mailing Address - Phone:805-582-7507
Mailing Address - Fax:805-582-7514
Practice Address - Street 1:3855 ALAMO ST STE F
Practice Address - Street 2:SUITE 2032
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-2110
Practice Address - Country:US
Practice Address - Phone:805-582-7507
Practice Address - Fax:805-582-7514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS9781251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health