MEDICARE: MCLA PSYCHIATRIC MEDICAL GROUP A PROFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	103T00000X	Psychologist
2	1041C0700X	Clinical Social Worker
3	106H00000X	Marriage & Family Therapist
4	2084P0804X	Child & Adolescent Psychiatry Physician
5	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1083681290
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCLA PSYCHIATRIC MEDICAL GROUP A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	1560 E CHEVY CHASE DRIVE
Second Line	:	SUITE 130
City	:	GLENDALE
State	:	CA
Zip	:	91206-4140
Country	:	US
Telephone Number	:	818-240-0340
Fax Number	:	818-545-7672

Provider Business Practice Location Address
First Line	:	1560 E CHEVY CHASE DRIVE
Second Line	:	SUITE 130
City	:	GLENDALE
State	:	CA
Zip	:	91206-4140
Country	:	US
Telephone Number	:	818-240-0340
Fax Number	:	818-545-7672

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LUKAS ALEXANIAN
Credential	:	MD
Telephone Number	:	818-240-0340

Provider Enumeration Date	:	03/07/2006
Last Update Date	:	11/23/2015

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