Healthcare Provider Details

I. General information

NPI: 1043364060
Provider Name (Legal Business Name): SAROSH MOTIVALA PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MEDICAL PLZ
LOS ANGELES CA
90095-0001
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 200
LOS ANGELES CA
90045-5632
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-9989
  • Fax:
Mailing address:
  • Phone: 310-301-8708
  • Fax: 310-301-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPSY21159
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: