Healthcare Provider Details

I. General information

NPI: 1205632965
Provider Name (Legal Business Name): MR. THERAPIST, INDIVIDUAL & FAMILY THERAPY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2025
Last Update Date: 02/24/2025
Certification Date: 02/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 CALLE AMANECER
SAN CLEMENTE CA
92673-6214
US

IV. Provider business mailing address

1000 CALLE AMANECER
SAN CLEMENTE CA
92673-6214
US

V. Phone/Fax

Practice location:
  • Phone: 949-466-1560
  • Fax:
Mailing address:
  • Phone: 949-466-1560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. EMMANUEL ROMERO
Title or Position: OWNER
Credential: LMFT
Phone: 949-466-1560