Provider Demographics
NPI:1316385636
Name:BISSELL, GONI HARY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GONI
Middle Name:HARY
Last Name:BISSELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3756 MOORE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-3533
Mailing Address - Country:US
Mailing Address - Phone:310-710-4817
Mailing Address - Fax:
Practice Address - Street 1:11340 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 185
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1608
Practice Address - Country:US
Practice Address - Phone:424-625-8077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-08
Last Update Date:2013-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25713103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical