=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578949293
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANAGEDMED INC., A PSYCHOLOGICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2015
-----------------------------------------------------
Last Update Date | 08/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5455 WILSHIRE BLVD STE 2000
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90036-4280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-934-3861
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5455 WILSHIRE BLVD STE 2000
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90036-4280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-934-3861
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PSYCHOLOGIST
-----------------------------------------------------
Name | NICHOLE JANELLE MCKENZIE
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 323-934-3861
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 27389
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------