Healthcare Provider Details

I. General information

NPI: 1801211404
Provider Name (Legal Business Name): NICOLE MEVORAK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2014
Last Update Date: 02/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11712 MOORPARK ST SUITE 114
STUDIO CITY CA
91604-2154
US

IV. Provider business mailing address

11712 MOORPARK ST SUITE 114
STUDIO CITY CA
91604-2154
US

V. Phone/Fax

Practice location:
  • Phone: 818-400-7311
  • Fax:
Mailing address:
  • Phone: 818-400-7311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number52895
License Number StateCA

VIII. Authorized Official

Name: MRS. NICOLE DAVINA MEVORAK
Title or Position: LICENSED MARRIAGE FAMILY THERAPIST
Credential: M.S.
Phone: 818-400-7311