Healthcare Provider Details

I. General information

NPI: 1265649792
Provider Name (Legal Business Name): PRACTICAL PSYCHOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 03/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 HUNTINGTON DR #104
DUARTE CA
91010-2567
US

IV. Provider business mailing address

2629 CALLE MARTOS
DUARTE CA
91010-2251
US

V. Phone/Fax

Practice location:
  • Phone: 626-808-7152
  • Fax: 888-898-4591
Mailing address:
  • Phone: 626-808-7152
  • Fax: 888-898-4591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY19391
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY19391
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPSY19391
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY19391
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY19391
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY19391
License Number StateCA

VIII. Authorized Official

Name: DR. EVAN D LANDRUM
Title or Position: OWNER
Credential: PSY.D
Phone: 626-808-7152