MEDICARE: DR. MARY KATHLEEN PASSEHL MFT, PSY.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	35693	CA

General Provider Information

NPI Number	:	1053628388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY KATHLEEN PASSEHL MFT, PSY.D

Provider Business Mailing Address
First Line	:	24637 GARDENSTONE LN
Second Line	:
City	:	WEST HILLS
State	:	CA
Zip	:	91307-3815
Country	:	US
Telephone Number	:	805-427-3718
Fax Number	:

Provider Business Practice Location Address
First Line	:	11965 VENICE BLVD
Second Line	:	SUITE 405
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-3979
Country	:	US
Telephone Number	:	310-566-7625
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2010
Last Update Date	:	09/08/2010

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