Healthcare Provider Details

I. General information

NPI: 1053746297
Provider Name (Legal Business Name): YULIA KOBA ANTONIADOU PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2013
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3812 SEPULVEDA BLVD
TORRANCE CA
90505-2413
US

IV. Provider business mailing address

3812 SEPULVEDA BLVD
TORRANCE CA
90505-4883
US

V. Phone/Fax

Practice location:
  • Phone: 310-388-7770
  • Fax:
Mailing address:
  • Phone: 323-478-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number30144
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: