Healthcare Provider Details

I. General information

NPI: 1609423268
Provider Name (Legal Business Name): MYRTLE MC INTOSH KALUGIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2019
Last Update Date: 08/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13710 LA MIRADA BLVD
LA MIRADA CA
90638-3028
US

IV. Provider business mailing address

13710 LA MIRADA BLVD
LA MIRADA CA
90638-3028
US

V. Phone/Fax

Practice location:
  • Phone: 562-943-0195
  • Fax: 562-902-2962
Mailing address:
  • Phone: 562-943-0195
  • Fax: 562-902-2962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMFT48824
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: