MEDICARE: IVAN WEST GREENSPAN PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY18686	CA

General Provider Information

NPI Number	:	1013154301
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVAN WEST GREENSPAN PSY.D.

Provider Business Mailing Address
First Line	:	6022 EVENHAIM LN
Second Line	:
City	:	TARZANA
State	:	CA
Zip	:	91356-1162
Country	:	US
Telephone Number	:	818-970-3172
Fax Number	:

Provider Business Practice Location Address
First Line	:	4849 VAN NUYS BLVD
Second Line	:
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91403-2110
Country	:	US
Telephone Number	:	818-970-3172
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2009
Last Update Date	:	01/08/2009

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