Healthcare Provider Details

I. General information

NPI: 1669806162
Provider Name (Legal Business Name): JUSTIN UNDERWOOD PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2013
Last Update Date: 04/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3580 WILSHIRE BLVD STE 2000
LOS ANGELES CA
90010-2533
US

IV. Provider business mailing address

500 E OLIVE AVE STE 540
BURBANK CA
91501-2132
US

V. Phone/Fax

Practice location:
  • Phone: 615-512-9660
  • Fax:
Mailing address:
  • Phone: 818-446-2522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number30190
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: