Healthcare Provider Details

I. General information

NPI: 1427624121
Provider Name (Legal Business Name): PATRICK TULLY LICENSED MARRIAGE AND FAMILY THERAPIST INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 11/23/2023
Certification Date: 11/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3685 MOTOR AVE STE 220
LOS ANGELES CA
90034-5746
US

IV. Provider business mailing address

10866 WASHINGTON BLVD # 1329
CULVER CITY CA
90232-3610
US

V. Phone/Fax

Practice location:
  • Phone: 323-819-0747
  • Fax:
Mailing address:
  • Phone: 323-819-0747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: PATRICK DAVEY TULLY
Title or Position: OWNER/PRESIDENT/CEO
Credential: MA, LMFT
Phone: 323-819-0747