MEDICARE: RUARK PSYCHOTHERAPY APC

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	MFT34153	CA
2	103T00000X	Psychologist	PSY10329	CA

General Provider Information

NPI Number	:	1780081547
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUARK PSYCHOTHERAPY APC

Provider Business Mailing Address
First Line	:	9854 NATIONAL BLVD
Second Line	:	SUITE 372
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-2713
Country	:	US
Telephone Number	:	310-837-7979
Fax Number	:

Provider Business Practice Location Address
First Line	:	3020 CASTLE HEIGHTS AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-2753
Country	:	US
Telephone Number	:	310-837-7979
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DANIEL RUARK
Credential	:	M.A., M.F.T.
Telephone Number	:	310-837-7979

Provider Enumeration Date	:	11/21/2014
Last Update Date	:	11/21/2014

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