=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003079484
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARTHA S. ALLEN-MILES MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2008
-----------------------------------------------------
Last Update Date | 07/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 975 FLYNN RD
-----------------------------------------------------
City | CAMARILLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93012-8704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-388-7740
-----------------------------------------------------
Fax | 805-482-0987
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 975 FLYNN RD
-----------------------------------------------------
City | CAMARILLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93012-8704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-986-2420
-----------------------------------------------------
Fax | 818-986-2420
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC41268
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------