=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598129017
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ILYA SHTYKAN LMFT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2016
-----------------------------------------------------
Last Update Date | 05/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1133 N DETROIT ST APT 2
-----------------------------------------------------
City | WEST HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90046-5843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-770-0654
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18735 HATTERAS ST UNIT 42
-----------------------------------------------------
City | TARZANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91356-1467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | LMFT128586
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------