Basic Information
| Provider Information | |||||||||
| NPI: | 1821303355 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMAZAN | ||||||||
| FirstName: | MIRLANDE | ||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | HALL | ||||||||
| OtherFirstName: | MIRLANDE | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1902 PALOMINO DR | ||||||||
| Address2: | |||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917914323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264306255 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1200 WILSHIRE BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900171908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134817464 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2010 | ||||||||
| LastUpdateDate: | 08/09/2010 | ||||||||
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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 | 1041C0700X | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.