MEDICARE: SEAPORT FAMILY THERAPY SERVICES, INC

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	93806	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	93806	OTHER	CA	CA BBS LMFT

General Provider Information

NPI Number	:	1912453739
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEAPORT FAMILY THERAPY SERVICES, INC

Provider Business Mailing Address
First Line	:	17155 NEWHOPE ST STE L
Second Line	:
City	:	FOUNTAIN VALLEY
State	:	CA
Zip	:	92708-4233
Country	:	US
Telephone Number	:	714-494-9136
Fax Number	:

Provider Business Practice Location Address
First Line	:	17155 NEWHOPE ST STE L
Second Line	:
City	:	FOUNTAIN VALLEY
State	:	CA
Zip	:	92708-4233
Country	:	US
Telephone Number	:	714-494-9136
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	NICOLE SABATINI GUTIERREZ
Credential	:
Telephone Number	:	714-494-9136

Provider Enumeration Date	:	08/31/2016
Last Update Date	:	08/31/2016

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