Healthcare Provider Details

I. General information

NPI: 1477072718
Provider Name (Legal Business Name): MARIKO IWABUCHI PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2017
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date: 10/03/2020
Reactivation Date: 11/10/2020

III. Provider practice location address

4605 LANKERSHIM BLVD STE 545
NORTH HOLLYWOOD CA
91602-1818
US

IV. Provider business mailing address

14900 MAGNOLIA BLVD # 5505
SHERMAN OAKS CA
91413-7001
US

V. Phone/Fax

Practice location:
  • Phone: 323-999-1395
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: