=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992729792
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IRA NATHANSON PH.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 337 S BEVERLY DR SUITE 209
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90212-4315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-553-0066
-----------------------------------------------------
Fax | 310-826-8182
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 337 S BEVERLY DR SUITE 209
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90212-4315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-553-0066
-----------------------------------------------------
Fax | 310-826-8182
-----------------------------------------------------
=====================================================
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 | PSY2825
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------