Basic Information
| Provider Information | |||||||||
| NPI: | 1295021301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NERSISYAN | ||||||||
| FirstName: | NELLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40255 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911147255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262968900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1845 N FAIR OAKS AVE | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911031620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262968900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2011 | ||||||||
| LastUpdateDate: | 06/27/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.