Provider Demographics
NPI:1144640491
Name:MY PRIVATE PRACTICE, INC.
Entity type:Organization
Organization Name:MY PRIVATE PRACTICE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:310-569-8321
Mailing Address - Street 1:3201 WILSHIRE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-2337
Mailing Address - Country:US
Mailing Address - Phone:310-569-8321
Mailing Address - Fax:310-829-7868
Practice Address - Street 1:3201 WILSHIRE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-2337
Practice Address - Country:US
Practice Address - Phone:310-569-8321
Practice Address - Fax:310-829-7868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty