Healthcare Provider Details

I. General information

NPI: 1487137295
Provider Name (Legal Business Name): REBECCA SUCHOV PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2018
Last Update Date: 02/10/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 S SEPULVEDA BLVD STE 110
LOS ANGELES CA
90034-6060
US

IV. Provider business mailing address

10300 VENICE BLVD PH 507
CULVER CITY CA
90232-3534
US

V. Phone/Fax

Practice location:
  • Phone: 310-421-9917
  • Fax:
Mailing address:
  • Phone: 818-571-7008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY34024
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: