Basic Information
| Provider Information | |||||||||
| NPI: | 1558683201 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUYLE | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 FAIR OAKS AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | SOUTH PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910302694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233415580 | ||||||||
| FaxNumber: | 3233408298 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 W 6TH ST STE 111 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900171823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234041027 | ||||||||
| FaxNumber: | 3233408298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2010 | ||||||||
| LastUpdateDate: | 02/23/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 6301001760 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TS0200X | 235724 | MI | N | Behavioral Health & Social Service Providers | Psychologist | School |
No ID Information.