Provider Demographics
NPI:1902834252
Name:MEBANE, D LOUISE (PHD)
Entity type:Individual
Prefix:
First Name:D
Middle Name:LOUISE
Last Name:MEBANE
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 1:1628 ELLSMERE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019
Mailing Address - Country:US
Mailing Address - Phone:310-262-2033
Mailing Address - Fax:323-933-5769
Practice Address - Street 1:153 SO LASKY DR
Practice Address - Street 2:#8
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212
Practice Address - Country:US
Practice Address - Phone:310-262-2033
Practice Address - Fax:323-933-5769
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12373103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY123732Medicaid
CAPSY12373Medicare PIN