Provider Demographics
NPI:1093495640
Name:SHEGELMAN, DMITRIY (RADT)
Entity Type:Individual
Prefix:MR
First Name:DMITRIY
Middle Name:
Last Name:SHEGELMAN
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5675 W. OLYMPIC BLVD.
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036
Mailing Address - Country:US
Mailing Address - Phone:323-965-1365
Mailing Address - Fax:323-965-0444
Practice Address - Street 1:5675 W. OLYMPIC BLVD.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036
Practice Address - Country:US
Practice Address - Phone:323-965-1365
Practice Address - Fax:323-965-0444
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1511500623171M00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator