Healthcare Provider Details

I. General information

NPI: 1437429578
Provider Name (Legal Business Name): MARY RITA SEVILLA MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2012
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 WESTCHESTER PL
LOS ANGELES CA
90019-3523
US

IV. Provider business mailing address

12001 CHALON RD
LOS ANGELES CA
90049-1526
US

V. Phone/Fax

Practice location:
  • Phone: 310-954-4432
  • Fax:
Mailing address:
  • Phone: 310-954-4432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC28088
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: