=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477962504
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JUDITH BERK MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2014
-----------------------------------------------------
Last Update Date | 08/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6464 W SUNSET BLVD STE 1040
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90028-8012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-836-0900
-----------------------------------------------------
Fax | 323-836-0901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15250 VENTURA BLVD STE 710
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91403-3219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-385-3100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JUDITH BERK
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 323-836-0900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | G27256
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------