Provider Demographics
NPI:1548462195
Name:RUSS, DAHLIA NISSAN (PSYD, LCSW)
Entity type:Individual
Prefix:DR
First Name:DAHLIA
Middle Name:NISSAN
Last Name:RUSS
Suffix:
Gender:F
Credentials:PSYD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 FAIRBURN AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-5958
Mailing Address - Country:US
Mailing Address - Phone:310-234-9115
Mailing Address - Fax:818-906-9920
Practice Address - Street 1:1800 FAIRBURN AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5958
Practice Address - Country:US
Practice Address - Phone:310-234-9115
Practice Address - Fax:818-906-9920
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALSC180461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical