=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629187349
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY NEUBAUER COHEN PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11301 WILSHIRE BLVD MIRECC; BLDG 210; ROOM 130
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90073-1003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-478-3711
-----------------------------------------------------
Fax | 310-268-4056
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1102 11TH ST APT 201
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90403-5322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-478-3711
-----------------------------------------------------
Fax | 310-268-4056
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY18952
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------