Healthcare Provider Details

I. General information

NPI: 1720397995
Provider Name (Legal Business Name): MONIQUE SHYLAKE PURRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2010
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2594 INDUSTRY WAY
LYNWOOD CA
90262-4015
US

IV. Provider business mailing address

2594 INDUSTRY WAY
LYNWOOD CA
90262-4015
US

V. Phone/Fax

Practice location:
  • Phone: 310-667-4070
  • Fax:
Mailing address:
  • Phone: 310-667-4070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW30799
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW79727
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number118998
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW79727
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: