Provider Demographics
NPI:1609423268
Name:KALUGIN, MYRTLE MC INTOSH
Entity Type:Individual
Prefix:
First Name:MYRTLE
Middle Name:MC INTOSH
Last Name:KALUGIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13710 LA MIRADA BLVD
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-3028
Mailing Address - Country:US
Mailing Address - Phone:562-943-0195
Mailing Address - Fax:562-902-2962
Practice Address - Street 1:13710 LA MIRADA BLVD
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-3028
Practice Address - Country:US
Practice Address - Phone:562-943-0195
Practice Address - Fax:562-902-2962
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT48824101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
106H00000XOtherWASHINGTON OUBLISHING COMPANY