Healthcare Provider Details

I. General information

NPI: 1265984215
Provider Name (Legal Business Name): MEGAN MANSFIELD PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date: 01/14/2020
Reactivation Date: 01/24/2020

III. Provider practice location address

6363 WILSHIRE BLVD STE 520
LOS ANGELES CA
90048-5727
US

IV. Provider business mailing address

6363 WILSHIRE BLVD STE 520
LOS ANGELES CA
90048-5727
US

V. Phone/Fax

Practice location:
  • Phone: 424-278-4225
  • Fax:
Mailing address:
  • Phone: 424-278-4225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY31497
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: