Provider Demographics
NPI:1891420907
Name:BIRNBAUM, CASEY LIZA (MFT)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:LIZA
Last Name:BIRNBAUM
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:CASEY
Other - Middle Name:LIZA
Other - Last Name:TASLITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFT
Mailing Address - Street 1:1831 OLD ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-2231
Mailing Address - Country:US
Mailing Address - Phone:847-924-0801
Mailing Address - Fax:
Practice Address - Street 1:11340 W OLYMPIC BLVD STE 330
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1613
Practice Address - Country:US
Practice Address - Phone:310-741-7831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132204106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty