Healthcare Provider Details

I. General information

NPI: 1982140901
Provider Name (Legal Business Name): MINERVA MENTAL HEALTH P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2017
Last Update Date: 01/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4448 AMBROSE AVE
LOS ANGELES CA
90027-2115
US

IV. Provider business mailing address

4448 AMBROSE AVE
LOS ANGELES CA
90027-2115
US

V. Phone/Fax

Practice location:
  • Phone: 323-644-1998
  • Fax: 323-644-2600
Mailing address:
  • Phone: 323-644-1998
  • Fax: 323-644-2600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA91413
License Number StateCA

VIII. Authorized Official

Name: DR. MILICA STEFANOVIC
Title or Position: PRESIDENT
Credential: M.D.
Phone: 323-644-1998