Healthcare Provider Details

I. General information

NPI: 1417540204
Provider Name (Legal Business Name): EVAN DUNN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2021
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11712 MOORPARK ST
STUDIO CITY CA
91604-2154
US

IV. Provider business mailing address

1811 N CHEROKEE AVE APT 26
LOS ANGELES CA
90028-4670
US

V. Phone/Fax

Practice location:
  • Phone: 818-425-9925
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number114385
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: