MEDICARE: DEBORAH SIRY ARDOLINO LPC LMFT

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	101YP2500X	Professional Counselor	LPC-12889	AZ
2	106H00000X	Marriage & Family Therapist	MFC 41978	CA

General Provider Information

NPI Number	:	1962754515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBORAH SIRY ARDOLINO LPC LMFT

Provider Business Mailing Address
First Line	:	18685 MAIN ST
Second Line	:	SUITE 101-348
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92648-1723
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	18685 MAIN ST
Second Line	:	SUITE 101-348
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92648-1723
Country	:	US
Telephone Number	:	310-874-4365
Fax Number	:

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

Provider Enumeration Date	:	10/05/2012
Last Update Date	:	10/05/2012

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