Provider Demographics
NPI:1982727095
Name:BERSUDSKY, SHANA ELYSE
Entity Type:Individual
Prefix:MRS
First Name:SHANA
Middle Name:ELYSE
Last Name:BERSUDSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5465 NEWCASTLE AVE
Mailing Address - Street 2:# 2
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-2077
Mailing Address - Country:US
Mailing Address - Phone:818-345-4823
Mailing Address - Fax:
Practice Address - Street 1:2055 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-1324
Practice Address - Country:US
Practice Address - Phone:626-798-6793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52660106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist