=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477072718
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIKO IWABUCHI PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2017
-----------------------------------------------------
Last Update Date | 01/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4605 LANKERSHIM BLVD STE 545
-----------------------------------------------------
City | NORTH HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91602-1818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-999-1395
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14900 MAGNOLIA BLVD # 5505
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91413-7001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------