Provider Demographics
NPI:1083491732
Name:NODELMAN, MITCH
Entity Type:Individual
Prefix:
First Name:MITCH
Middle Name:
Last Name:NODELMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5805 SEPULVEDA BLVD STE 710
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-2522
Mailing Address - Country:US
Mailing Address - Phone:213-637-5000
Mailing Address - Fax:
Practice Address - Street 1:5805 SEPULVEDA BLVD STE 710
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-2522
Practice Address - Country:US
Practice Address - Phone:213-637-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-14
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA142547106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner