Basic Information
| Provider Information | |||||||||
| NPI: | 1629427646 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MALAKUTI PSYCHOLOGICAL HEALTH GROUP INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KATRIN MALAKUTI | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9171 WILSHIRE BLVD STE 660 | ||||||||
| Address2: | |||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902105540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4246457793 | ||||||||
| FaxNumber: | 3102731010 | ||||||||
| Practice Location | |||||||||
| Address1: | 9171 WILSHIRE BLVD STE 660 | ||||||||
| Address2: | |||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902105540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4246457793 | ||||||||
| FaxNumber: | 3102731010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2016 | ||||||||
| LastUpdateDate: | 06/09/2016 | ||||||||
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| AuthorizedOfficialLastName: | MALAKUTI | ||||||||
| AuthorizedOfficialFirstName: | KATRIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4246457793 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PSY.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY26550 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | CB226632 | 05 | CA | MEDICAID |