1013125905 NPI number — MS. SHELLEY MERI PUSICH MA,MFT

Table of content: MS. SHELLEY MERI PUSICH MA,MFT (NPI 1013125905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013125905 NPI number — MS. SHELLEY MERI PUSICH MA,MFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PUSICH
Provider First Name:
SHELLEY
Provider Middle Name:
MERI
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA,MFT
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:
1013125905
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:
520 S SEPULVEDA BLVD
Provider Second Line Business Mailing Address:
SUITE 306
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90049-3521
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-440-8809
Provider Business Mailing Address Fax Number:
323-651-4145

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
520 S SEPULVEDA BLVD
Provider Second Line Business Practice Location Address:
SUITE 306
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90049-3521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-440-8809
Provider Business Practice Location Address Fax Number:
323-651-3145
Provider Enumeration Date:
05/21/2007

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: 106H00000X , with the licence number:  MFC24615 , 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)





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