Provider Demographics
NPI:1588952055
Name:KUSSIN-SHOPTAW, ALEXANDRA LILLIAN (PHD)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:LILLIAN
Last Name:KUSSIN-SHOPTAW
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13400 RIVERSIDE DR STE 318
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-2501
Mailing Address - Country:US
Mailing Address - Phone:323-418-2103
Mailing Address - Fax:
Practice Address - Street 1:13400 RIVERSIDE DR STE 318
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-2501
Practice Address - Country:US
Practice Address - Phone:323-418-2103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY30547103TH0100X, 103TC0700X, 103TC2200X, 103TF0000X
390200000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily