Healthcare Provider Details

I. General information

NPI: 1245847029
Provider Name (Legal Business Name): MIA RAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 HAMPTON DR
VENICE CA
90291-8633
US

IV. Provider business mailing address

1625 SCHRADER BLVD
LOS ANGELES CA
90028-6213
US

V. Phone/Fax

Practice location:
  • Phone: 626-265-0750
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT133704
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01536011
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerMEDI-CAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: