Healthcare Provider Details

I. General information

NPI: 1437539509
Provider Name (Legal Business Name): EHAB YACOUB MD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2015
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 W 190TH ST STE 470
GARDENA CA
90248-4305
US

IV. Provider business mailing address

14541 DELANO ST
VAN NUYS CA
91411-2820
US

V. Phone/Fax

Practice location:
  • Phone: 310-515-8113
  • Fax:
Mailing address:
  • Phone: 877-515-8113
  • Fax: 877-538-2102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA76244
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. EHAB S YACOUB
Title or Position: CEO
Credential:
Phone: 877-515-8113