Provider Demographics
NPI:1811147713
Name:NESOVIC, SLOBODAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:SLOBODAN
Middle Name:
Last Name:NESOVIC
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 W 6TH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1833
Mailing Address - Country:US
Mailing Address - Phone:213-202-3970
Mailing Address - Fax:213-202-3977
Practice Address - Street 1:1125 W 6TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017
Practice Address - Country:US
Practice Address - Phone:213-202-3970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-26
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 225C00000X
CAPSY28761103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical