Provider Demographics
NPI:1578949293
Name:MANAGEDMED INC., A PSYCHOLOGICAL CORPORATION
Entity Type:Organization
Organization Name:MANAGEDMED INC., A PSYCHOLOGICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:JANELLE
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:323-934-3861
Mailing Address - Street 1:5455 WILSHIRE BLVD STE 2000
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-4280
Mailing Address - Country:US
Mailing Address - Phone:323-934-3861
Mailing Address - Fax:
Practice Address - Street 1:5455 WILSHIRE BLVD STE 2000
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4280
Practice Address - Country:US
Practice Address - Phone:323-934-3861
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27389103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty