MEDICARE: DR. REBECCA SUCHOV PSYD

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	390200000X	Student in an Organized Health Care Education/Training Program
2	103TC0700X	Clinical Psychologist	PSY34024	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0	OTHER		MEDICAL

General Provider Information

NPI Number	:	1487137295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. REBECCA SUCHOV PSYD

Provider Business Mailing Address
First Line	:	10300 VENICE BLVD PH 507
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90232-3534
Country	:	US
Telephone Number	:	818-571-7008
Fax Number	:

Provider Business Practice Location Address
First Line	:	3415 S SEPULVEDA BLVD STE 110
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-6060
Country	:	US
Telephone Number	:	310-421-9917
Fax Number	:

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

Provider Enumeration Date	:	09/09/2018
Last Update Date	:	02/10/2023

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