MEDICARE: STRAIGHT UP TREATMENT, INC.

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	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1396221016
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STRAIGHT UP TREATMENT, INC.

Provider Business Mailing Address
First Line	:	330 N SCREENLAND DR APT 327
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-3870
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1180 S BEVERLY DR STE 401
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-1156
Country	:	US
Telephone Number	:	424-235-7095
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	CHRISTINE IZQUIERDO
Credential	:	PSY.D.
Telephone Number	:	424-235-7095

Provider Enumeration Date	:	07/16/2018
Last Update Date	:	07/16/2018

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