Provider Demographics
NPI:1386874790
Name:BODURYAN, MENIJE (PSYD)
Entity type:Individual
Prefix:
First Name:MENIJE
Middle Name:
Last Name:BODURYAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7112 DARNOCH WAY
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-1835
Mailing Address - Country:US
Mailing Address - Phone:818-575-6148
Mailing Address - Fax:
Practice Address - Street 1:4505 LAS VIRGENES RD
Practice Address - Street 2:SUITE 205
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91302-1956
Practice Address - Country:US
Practice Address - Phone:818-575-6148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26351101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7420Medicaid
CA7068Medicaid