MEDICARE: MINDFUL GUIDES, A MARRIAGE AND FAMILY THERAPY CORPORATION

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	42737	CA

General Provider Information

NPI Number	:	1174059687
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL GUIDES, A MARRIAGE AND FAMILY THERAPY CORPORATION

Provider Business Mailing Address
First Line	:	7734 HERSCHEL AVE
Second Line	:	SUITE O
City	:	LA JOLLA
State	:	CA
Zip	:	92037-4433
Country	:	US
Telephone Number	:	858-442-5548
Fax Number	:

Provider Business Practice Location Address
First Line	:	7734 HERSCHEL AVE
Second Line	:	SUITE O
City	:	LA JOLLA
State	:	CA
Zip	:	92037-4433
Country	:	US
Telephone Number	:	858-442-5548
Fax Number	:

Authorized Official
Title or Position	:	OWNER, LICENSED MFT
Name	:	NICOLE KAHN
Credential	:
Telephone Number	:	858-442-5548

Provider Enumeration Date	:	05/03/2017
Last Update Date	:	05/03/2017

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