Healthcare Provider Details

I. General information

NPI: 1710422506
Provider Name (Legal Business Name): MY SHADOW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2017
Last Update Date: 01/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 W OLYMPIC BLVD SUITE 300
LOS ANGELES CA
90064-1653
US

IV. Provider business mailing address

11301 W OLYMPIC BLVD SUITE 300
LOS ANGELES CA
90064-1653
US

V. Phone/Fax

Practice location:
  • Phone: 310-721-2101
  • Fax:
Mailing address:
  • Phone: 310-721-2101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: NATASHA PARSAKIA
Title or Position: OWNER/SUPERVISOR/BCBA
Credential: MA, BCBA
Phone: 310-721-2101