Healthcare Provider Details

I. General information

NPI: 1568685592
Provider Name (Legal Business Name): BONNIE G ZUCKER PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STUDENT PSYCHOLOGICAL SERVICES JOHN WOODEN CTR W 221 WESTWOOD PLAZA, BOX 951556
LOS ANGELES CA
90095-1556
US

IV. Provider business mailing address

STUDENT PSYCHOLOGICAL SERVICES JOHN WOODEN CTR W 221 WESTWOOD PLAZA, BOX 951556
LOS ANGELES CA
90095-1556
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-6878
  • Fax:
Mailing address:
  • Phone: 310-206-6878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY20391
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: