1992822068 NPI number — DR. SUSAN LEE MENDENHALL MSW PSYD

Table of content: DR. SUSAN LEE MENDENHALL MSW PSYD (NPI 1992822068)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992822068 NPI number — DR. SUSAN LEE MENDENHALL MSW PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENDENHALL
Provider First Name:
SUSAN
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MSW PSYD
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:
1992822068
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:
10436 SANTA MONICA BLVD
Provider Second Line Business Mailing Address:
#3050
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-558-8091
Provider Business Mailing Address Fax Number:
310-204-4028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10436 SANTA MONICA BLVD
Provider Second Line Business Practice Location Address:
#3050
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-558-8091
Provider Business Practice Location Address Fax Number:
310-204-4028
Provider Enumeration Date:
03/23/2007

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:  LCS3284 , 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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