Provider Demographics
NPI:1164796793
Name:DUSIG, MAXINE JUDITH (MA)
Entity Type:Individual
Prefix:MRS
First Name:MAXINE
Middle Name:JUDITH
Last Name:DUSIG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-2344
Mailing Address - Country:US
Mailing Address - Phone:310-828-2323
Mailing Address - Fax:310-344-4808
Practice Address - Street 1:18757 BURBANK BLVD STE 125
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3345
Practice Address - Country:US
Practice Address - Phone:310-828-2323
Practice Address - Fax:818-912-6042
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-29
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25445106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA25445OtherLICENSE NUMBER