Healthcare Provider Details

I. General information

NPI: 1710011176
Provider Name (Legal Business Name): ROMAN BLUESKYES LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3831 HUGHES AVE STE 708
CULVER CITY CA
90232
US

IV. Provider business mailing address

3200 MOTOR AVE
LOS ANGELES CA
90034-3710
US

V. Phone/Fax

Practice location:
  • Phone: 310-838-4403
  • Fax: 888-231-5872
Mailing address:
  • Phone: 310-837-6647
  • Fax: 310-837-6647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number43822
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: