MEDICARE: LONG BEACH CENTER FOR PSYCHOTHERAPY

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	46613	CA

General Provider Information

NPI Number	:	1053628719
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONG BEACH CENTER FOR PSYCHOTHERAPY

Provider Business Mailing Address
First Line	:	600 E OCEAN BLVD STE 400B
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90802-5013
Country	:	US
Telephone Number	:	562-987-3535
Fax Number	:	562-983-7367

Provider Business Practice Location Address
First Line	:	600 E OCEAN BLVD STE 400B
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90802-5013
Country	:	US
Telephone Number	:	562-987-3535
Fax Number	:	562-983-7367

Authorized Official
Title or Position	:	OWNER
Name	:	ETHEL DANIELS
Credential	:	MFT
Telephone Number	:	562-987-3535

Provider Enumeration Date	:	09/01/2010
Last Update Date	:	09/02/2010

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