Provider Demographics
NPI:1265791859
Name:MCDERMOTT, JAMES WILSON (MA)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:WILSON
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9040 HARRATT ST
Mailing Address - Street 2:35
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-3859
Mailing Address - Country:US
Mailing Address - Phone:424-202-8973
Mailing Address - Fax:
Practice Address - Street 1:9040 HARRATT ST
Practice Address - Street 2:35
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-3859
Practice Address - Country:US
Practice Address - Phone:424-202-8973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1065101YP2500X
CA42673106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional