Healthcare Provider Details

I. General information

NPI: 1770329781
Provider Name (Legal Business Name): KARL LJUNGQUIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2812 AVENEL ST
LOS ANGELES CA
90039-2047
US

IV. Provider business mailing address

4208 RUSSELL AVE APT 3
LOS ANGELES CA
90027-4551
US

V. Phone/Fax

Practice location:
  • Phone: 213-361-4563
  • Fax:
Mailing address:
  • Phone: 213-361-4563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: