Healthcare Provider Details

I. General information

NPI: 1104330547
Provider Name (Legal Business Name): MIVEN TRAGESER, LA CHILD THERAPIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2017
Last Update Date: 11/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6310 SAN VICENTE BLVD STE 415
LOS ANGELES CA
90048-5457
US

IV. Provider business mailing address

6310 SAN VICENTE BLVD STE 415
LOS ANGELES CA
90048-5457
US

V. Phone/Fax

Practice location:
  • Phone: 323-717-6803
  • Fax:
Mailing address:
  • Phone: 323-717-6803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1339
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number49725
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1339
License Number StateCA

VIII. Authorized Official

Name: MS. MIVEN BOOTH TRAGESER
Title or Position: PRINCIPAL
Credential: LMFT, LPCC
Phone: 323-813-8238