Healthcare Provider Details

I. General information

NPI: 1861913360
Provider Name (Legal Business Name): MICHELLE MARIE SOOHOO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD # 114
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

4650 SUNSET BLVD MS #114
LOS ANGELES CA
90027
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-8450
  • Fax:
Mailing address:
  • Phone: 323-361-8450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number32418
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: