Healthcare Provider Details

I. General information

NPI: 1346367455
Provider Name (Legal Business Name): RANI KANDATHIL MAMMEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RANI MAMMEN MAMMEN

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 AVENUE 64
PASADENA CA
91105
US

IV. Provider business mailing address

940 AVENUE 64
PASADENA CA
91105
US

V. Phone/Fax

Practice location:
  • Phone: 323-254-2274
  • Fax:
Mailing address:
  • Phone: 323-254-2274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS24846
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: