Basic Information
| Provider Information | |||||||||
| NPI: | 1275132581 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AHN | ||||||||
| FirstName: | JUNSOO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 COLUMBIA AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900171209 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 515 COLUMBIA AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900171209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2135531884 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2020 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | 102232 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.