Healthcare Provider Details

I. General information

NPI: 1336077650
Provider Name (Legal Business Name): SUSAN SCHMIDT-LACKNER A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2026
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1239 S CAMDEN DR
LOS ANGELES CA
90035-1111
US

IV. Provider business mailing address

1239 S CAMDEN DR
LOS ANGELES CA
90035-1111
US

V. Phone/Fax

Practice location:
  • Phone: 310-869-9119
  • Fax:
Mailing address:
  • Phone: 310-869-9119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: SUSAN L SCHMIDT-LACKNER
Title or Position: PRESIDENT CEO, SECRETARY AND CFO,
Credential: MD
Phone: 318-869-9119