Basic Information
| Provider Information | |||||||||
| NPI: | 1467932079 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEVORGYAN | ||||||||
| FirstName: | LUSINE | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | GEVORGYAN | ||||||||
| OtherFirstName: | LUCY | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7436 EL CENTRO WAY | ||||||||
| Address2: | |||||||||
| City: | BUENA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906201711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148228147 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1040 W TOWN AND COUNTRY RD BLDG G | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928684716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146458000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2018 | ||||||||
| LastUpdateDate: | 08/14/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041S0200X | Y | Behavioral Health & Social Service Providers | Social Worker | School |
No ID Information.