Provider Demographics
NPI:1588171615
Name:AUTAJAY, NINA PAYUYO
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:PAYUYO
Last Name:AUTAJAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5825 W OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-4612
Mailing Address - Country:US
Mailing Address - Phone:323-933-9022
Mailing Address - Fax:323-933-4029
Practice Address - Street 1:5825 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4612
Practice Address - Country:US
Practice Address - Phone:323-933-9022
Practice Address - Fax:323-933-4029
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1280181017101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)