Healthcare Provider Details

I. General information

NPI: 1114355237
Provider Name (Legal Business Name): WESTSIDE NEUROTHERAPEUTICS, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10850 WILSHIRE BLVD 1260
LOS ANGELES CA
90024-4305
US

IV. Provider business mailing address

10850 WILSHIRE BLVD 1260
LOS ANGELES CA
90024-4305
US

V. Phone/Fax

Practice location:
  • Phone: 310-946-0008
  • Fax: 310-209-0444
Mailing address:
  • Phone: 310-946-0008
  • Fax: 310-209-0444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY17275
License Number StateCA

VIII. Authorized Official

Name: DR. TANYA VAPNIK
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 310-946-0008