Provider Demographics
NPI:1932123197
Name:HERRMANN, EDNA (PHD PSY)
Entity Type:Individual
Prefix:DR
First Name:EDNA
Middle Name:
Last Name:HERRMANN
Suffix:
Gender:F
Credentials:PHD PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S FULLER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-2809
Mailing Address - Country:US
Mailing Address - Phone:323-939-0437
Mailing Address - Fax:323-939-7691
Practice Address - Street 1:101 S FULLER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-2809
Practice Address - Country:US
Practice Address - Phone:323-939-0437
Practice Address - Fax:323-939-7691
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4995103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY4995Medicaid
CAPSY4995Medicaid