Provider Demographics
NPI:1891153243
Name:SHAM, BONNY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BONNY
Middle Name:
Last Name:SHAM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1328 WESTWOOD BLVD STE 23
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-4931
Mailing Address - Country:US
Mailing Address - Phone:310-203-1568
Mailing Address - Fax:
Practice Address - Street 1:1328 WESTWOOD BLVD STE 23
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-4931
Practice Address - Country:US
Practice Address - Phone:310-203-1568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-31
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19539103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical