Healthcare Provider Details

I. General information

NPI: 1649748450
Provider Name (Legal Business Name): EXTRAORDINARY YOU/DR. AGNES OH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2018
Last Update Date: 12/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 N CENTRAL AVE # 315
GLENDALE CA
91202-2937
US

IV. Provider business mailing address

1010 N CENTRAL AVE # 315
GLENDALE CA
91202-2937
US

V. Phone/Fax

Practice location:
  • Phone: 818-245-1129
  • Fax:
Mailing address:
  • Phone: 818-245-1129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. AGNES OH
Title or Position: OWNER
Credential: PSYD
Phone: 818-441-1096