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General NPI Number Information
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NPI Number | 1003534900
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Entity Type | Individual
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Provider Name | MARI KONOSHIMA ANDERSEN
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Gender | Female
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Dates
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Enumeration Date | 08/16/2022
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Last Update Date | 08/16/2022
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Provider Practice Location Address
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Address Line | 3551 CAMINO MIRA COSTA STE T
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City | SAN CLEMENTE
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State | CA
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Zip | 92672-3508
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Country | US
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Telephone | 949-272-4444
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Fax |
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Provider Business Mailing Address
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Address Line | 1058 LA MIRADA ST
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City | LAGUNA BEACH
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State | CA
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Zip | 92651-3570
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Country | US
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Telephone | 949-228-1662
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 132206
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License Number State | CA
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