Provider Demographics
NPI:1497898910
Name:EZRA, NANCY LYNN (PHD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:LYNN
Last Name:EZRA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5623 KATHERINE AVE
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-4617
Mailing Address - Country:US
Mailing Address - Phone:818-905-8858
Mailing Address - Fax:310-829-8455
Practice Address - Street 1:1339 20TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2033
Practice Address - Country:US
Practice Address - Phone:818-905-8858
Practice Address - Fax:310-829-8455
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPS2012075225C00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor