Provider Demographics
NPI:1396989653
Name:STANISLAVSKY, MODJGAN M (MFT)
Entity type:Individual
Prefix:
First Name:MODJGAN
Middle Name:M
Last Name:STANISLAVSKY
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9300 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-3213
Mailing Address - Country:US
Mailing Address - Phone:310-358-9955
Mailing Address - Fax:
Practice Address - Street 1:9300 WILSHIRE BLVD
Practice Address - Street 2:SUITE 320
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-3213
Practice Address - Country:US
Practice Address - Phone:310-358-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-29
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC40026106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist