Healthcare Provider Details

I. General information

NPI: 1588952055
Provider Name (Legal Business Name): ALEXANDRA LILLIAN KUSSIN-SHOPTAW PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13400 RIVERSIDE DR STE 318
SHERMAN OAKS CA
91423-2501
US

IV. Provider business mailing address

13400 RIVERSIDE DR STE 318
SHERMAN OAKS CA
91423-2501
US

V. Phone/Fax

Practice location:
  • Phone: 323-418-2103
  • Fax:
Mailing address:
  • Phone: 323-418-2103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY30547
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY30547
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPSY30547
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberPSY30547
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: