Provider Demographics
NPI:1700404647
Name:MIRMELLI, JOSHUA LAWRENCE (PSYD)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:LAWRENCE
Last Name:MIRMELLI
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 N PALM DR UNIT 305
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4189
Mailing Address - Country:US
Mailing Address - Phone:305-333-9778
Mailing Address - Fax:
Practice Address - Street 1:11340 W OLYMPIC BLVD STE 305
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1630
Practice Address - Country:US
Practice Address - Phone:305-333-9778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31895103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty