Healthcare Provider Details

I. General information

NPI: 1174461982
Provider Name (Legal Business Name): ETHAN MICHAEL PEARSON AMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ETHAN MICHAEL HANSEN-PEARSON AMFT

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 W 9TH ST STE 103
SAN PEDRO CA
90731-3158
US

IV. Provider business mailing address

624 W 9TH ST STE 103
SAN PEDRO CA
90731-3158
US

V. Phone/Fax

Practice location:
  • Phone: 310-938-4575
  • Fax:
Mailing address:
  • Phone: 310-938-4575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number158083
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: