Provider Demographics
NPI:1730658972
Name:MANSOUR, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 W CENTINELA AVE STE 380
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-6367
Mailing Address - Country:US
Mailing Address - Phone:805-398-0525
Mailing Address - Fax:
Practice Address - Street 1:2550 N HOLLYWOOD WAY STE 102
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-5031
Practice Address - Country:US
Practice Address - Phone:866-727-8274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-16
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-21-52313103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst