Provider Demographics
NPI:1619139045
Name:MEGDAL, BROOKE
Entity Type:Individual
Prefix:MISS
First Name:BROOKE
Middle Name:
Last Name:MEGDAL
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 1:12011 SAN VICENTE BLVD
Mailing Address - Street 2:SUITE 408
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-4926
Mailing Address - Country:US
Mailing Address - Phone:310-968-1572
Mailing Address - Fax:
Practice Address - Street 1:12011 SAN VICENTE BLVD
Practice Address - Street 2:SUITE 408
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-4926
Practice Address - Country:US
Practice Address - Phone:310-968-1572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 42801106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist