Healthcare Provider Details

I. General information

NPI: 1073154928
Provider Name (Legal Business Name): MAKANDO MUTANDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 WILSHIRE BLVD
LOS ANGELES CA
90017-2216
US

IV. Provider business mailing address

1515 WILSHIRE BLVD APT 617
LOS ANGELES CA
90017-3028
US

V. Phone/Fax

Practice location:
  • Phone: 213-274-6593
  • Fax:
Mailing address:
  • Phone: 213-274-6593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number126547
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: