Provider Demographics
NPI:1114594694
Name:BAGAN, CHERYL L
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:L
Last Name:BAGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5757 W CENTURY BLVD STE 303
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-6409
Mailing Address - Country:US
Mailing Address - Phone:323-290-2540
Mailing Address - Fax:
Practice Address - Street 1:4240 W 62ND ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-3615
Practice Address - Country:US
Practice Address - Phone:323-290-2540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-04
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor