Provider Demographics
NPI:1861404782
Name:WELLISCH, DAVID (PHD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WELLISCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5632
Mailing Address - Country:US
Mailing Address - Phone:310-301-8708
Mailing Address - Fax:310-301-8751
Practice Address - Street 1:450 N BEDFORD DR STE 310
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4307
Practice Address - Country:US
Practice Address - Phone:310-710-6432
Practice Address - Fax:323-375-3204
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4936103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PSY49360OtherMEDICAL
CACP4936Medicare ID - Type Unspecified
CA0PSY49360OtherMEDICAL