Healthcare Provider Details

I. General information

NPI: 1982935276
Provider Name (Legal Business Name): MR. RICHARD MICHAEL LUBAROFF
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2010
Last Update Date: 01/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 GRAND VIEW BLVD
LOS ANGELES CA
90066-5214
US

IV. Provider business mailing address

10641 BUTTERFIELD RD
LOS ANGELES CA
90064-4313
US

V. Phone/Fax

Practice location:
  • Phone: 310-751-1149
  • Fax:
Mailing address:
  • Phone: 310-880-0043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number57538
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: