Healthcare Provider Details

I. General information

NPI: 1841570165
Provider Name (Legal Business Name): JEFFREY PAUL CARLSON MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 08/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16700 VALLEY VIEW AVE SUITE # 210
LA MIRADA CA
90638-5830
US

IV. Provider business mailing address

16700 VALLEY VIEW AVE SUITE # 210
LA MIRADA CA
90638-5830
US

V. Phone/Fax

Practice location:
  • Phone: 714-994-0500
  • Fax: 714-994-0515
Mailing address:
  • Phone: 714-994-0500
  • Fax: 714-994-0515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 38441
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: