Healthcare Provider Details

I. General information

NPI: 1215067194
Provider Name (Legal Business Name): RUZANNA AGAMYAN PHD UNLICENSED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 12/27/2023
Certification Date: 12/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3208 ROSEMEAD BLVD ENKI
EL MONTE CA
91731
US

IV. Provider business mailing address

201 E ANGELENO AVE UNIT 403
BURBANK CA
91502-2956
US

V. Phone/Fax

Practice location:
  • Phone: 626-227-7001
  • Fax: 626-227-7002
Mailing address:
  • Phone: 818-415-2058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number21548
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: