Healthcare Provider Details

I. General information

NPI: 1811231020
Provider Name (Legal Business Name): ROBERT SEAN VAZZANA LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2012
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 N LARCHMONT BLVD
LOS ANGELES CA
90004-1307
US

IV. Provider business mailing address

PO BOX 452601
LOS ANGELES CA
90045-8535
US

V. Phone/Fax

Practice location:
  • Phone: 323-374-5222
  • Fax:
Mailing address:
  • Phone: 702-279-2877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number112270
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: