Provider Demographics
NPI:1649748450
Name:EXTRAORDINARY YOU/DR. AGNES OH
Entity Type:Organization
Organization Name:EXTRAORDINARY YOU/DR. AGNES OH
Other - Org Name:DR. AGNES OH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:
Authorized Official - Last Name:OH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:818-441-1096
Mailing Address - Street 1:1010 N CENTRAL AVE # 315
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-2937
Mailing Address - Country:US
Mailing Address - Phone:818-245-1129
Mailing Address - Fax:
Practice Address - Street 1:1010 N CENTRAL AVE # 315
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-2937
Practice Address - Country:US
Practice Address - Phone:818-245-1129
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-09
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty