Provider Demographics
NPI:1245598150
Name:BOSURGI, LUCA (DHYP, MBSH)
Entity Type:Individual
Prefix:
First Name:LUCA
Middle Name:
Last Name:BOSURGI
Suffix:
Gender:M
Credentials:DHYP, MBSH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2812 SANTA MONICA BLVD. #205
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404
Mailing Address - Country:US
Mailing Address - Phone:310-623-7289
Mailing Address - Fax:
Practice Address - Street 1:2812 SANTA MONICA BLVD. #205
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-623-7289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-27
Last Update Date:2019-04-04
Deactivation Date:2017-02-07
Deactivation Code:
Reactivation Date:2019-04-04
Provider Licenses
StateLicense IDTaxonomies
WAHP 60277907101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health