Provider Demographics
NPI:1720457682
Name:BALASANYAN, MARIAM VASILYEVNA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARIAM
Middle Name:VASILYEVNA
Last Name:BALASANYAN
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 1:600 ST PAUL AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-2038
Mailing Address - Country:US
Mailing Address - Phone:213-482-6400
Mailing Address - Fax:213-482-6408
Practice Address - Street 1:600 ST PAUL AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-2038
Practice Address - Country:US
Practice Address - Phone:213-482-6400
Practice Address - Fax:213-482-6408
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103T00000XBehavioral Health & Social Service ProvidersPsychologist