Provider Demographics
NPI:1376873356
Name:CERNIN, PAUL ANTHONY (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:ANTHONY
Last Name:CERNIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 MAIN ST # 241
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-3803
Mailing Address - Country:US
Mailing Address - Phone:310-295-8666
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD BLDG 215
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-295-8666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-13
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009038152103TC0700X
CAPSY23762103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY237620Medicaid
CAEK676ZMedicare PIN