1548462195 NPI number — DR. DAHLIA NISSAN RUSS PSY.D., LCSW

Table of content: DR. DAHLIA NISSAN RUSS PSY.D., LCSW (NPI 1548462195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548462195 NPI number — DR. DAHLIA NISSAN RUSS PSY.D., LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSS
Provider First Name:
DAHLIA
Provider Middle Name:
NISSAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D., LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548462195
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1800 FAIRBURN AVE
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90025-5958
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-234-9115
Provider Business Mailing Address Fax Number:
818-906-9920

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 FAIRBURN AVE
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90025-5958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-234-9115
Provider Business Practice Location Address Fax Number:
818-906-9920
Provider Enumeration Date:
06/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LSC18046 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com