Provider Demographics
NPI:1942539945
Name:MINWALLA, OMAR (PHD)
Entity Type:Individual
Prefix:DR
First Name:OMAR
Middle Name:
Last Name:MINWALLA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S BEVERLY DR STE 316
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-4405
Mailing Address - Country:US
Mailing Address - Phone:310-286-1300
Mailing Address - Fax:310-286-1330
Practice Address - Street 1:400 S BEVERLY DR STE 316
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-4405
Practice Address - Country:US
Practice Address - Phone:310-286-1300
Practice Address - Fax:310-286-1330
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-22
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20244103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral