Provider Demographics
NPI:1720397995
Name:PURRY, MONIQUE SHYLAKE
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:SHYLAKE
Last Name:PURRY
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 1:2594 INDUSTRY WAY
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-4015
Mailing Address - Country:US
Mailing Address - Phone:310-667-4070
Mailing Address - Fax:
Practice Address - Street 1:2594 INDUSTRY WAY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-4015
Practice Address - Country:US
Practice Address - Phone:310-667-4070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW79727101YM0800X, 1041C0700X
CAASW30799101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health