Provider Demographics
NPI:1386678704
Name:HAUSWIRTH, JUDI BLOOM (PSYD)
Entity type:Individual
Prefix:DR
First Name:JUDI
Middle Name:BLOOM
Last Name:HAUSWIRTH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JUDI
Other - Middle Name:
Other - Last Name:BLOOM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:2100 SAWTELLE BLVD STE 206
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6264
Mailing Address - Country:US
Mailing Address - Phone:310-477-3808
Mailing Address - Fax:310-274-2366
Practice Address - Street 1:2100 SAWTELLE BLVD STE 206
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6264
Practice Address - Country:US
Practice Address - Phone:310-477-3808
Practice Address - Fax:310-274-2366
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT33367106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFT33367OtherLICENSE