Healthcare Provider Details

I. General information

NPI: 1831653781
Provider Name (Legal Business Name): DR. MIMI SHAGAGA INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2019
Last Update Date: 07/02/2020
Certification Date: 07/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20300 VENTURA BLVD STE 315
WOODLAND HILLS CA
91364-0903
US

IV. Provider business mailing address

13351D RIVERSIDE DR STE 598
SHERMAN OAKS CA
91423-2508
US

V. Phone/Fax

Practice location:
  • Phone: 424-274-2963
  • Fax:
Mailing address:
  • Phone: 424-274-2963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KARIMA SHAGAGA
Title or Position: PRESIDENT
Credential:
Phone: 424-274-2963