Healthcare Provider Details

I. General information

NPI: 1407908684
Provider Name (Legal Business Name): MARC JOSEPH MESTYANEK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23041 AVENIDA DE LA CARLOTA FL 4
LAGUNA HILLS CA
92653-1511
US

IV. Provider business mailing address

8314 RAYFORD DR
LOS ANGELES CA
90045-2430
US

V. Phone/Fax

Practice location:
  • Phone: 714-644-6480
  • Fax:
Mailing address:
  • Phone: 310-259-0458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number48264
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: