Healthcare Provider Details

I. General information

NPI: 1073902235
Provider Name (Legal Business Name): MIRJAM AFENI HATTON PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2015
Last Update Date: 02/24/2024
Certification Date: 02/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

958 VENANGO AVE
LOS ANGELES CA
90029-3020
US

IV. Provider business mailing address

PO BOX 27591
LOS ANGELES CA
90027-0591
US

V. Phone/Fax

Practice location:
  • Phone: 213-537-8565
  • Fax:
Mailing address:
  • Phone: 213-537-8565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number34098
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number98906
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: