MEDICARE: DR. PHILIP KELLY STENQUIST PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	PSY11042	CA

General Provider Information

NPI Number	:	1225194954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHILIP KELLY STENQUIST PH.D.

Provider Business Mailing Address
First Line	:	6230 WILSHIRE BLVD
Second Line	:	#37
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-5104
Country	:	US
Telephone Number	:	323-957-4700
Fax Number	:	661-291-1741

Provider Business Practice Location Address
First Line	:	6230 WILSHIRE BLVD
Second Line	:	#37
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-5104
Country	:	US
Telephone Number	:	323-957-4700
Fax Number	:	661-291-1741

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	07/08/2007

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