=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053825653
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | M.Y. THERAPY HEALING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2017
-----------------------------------------------------
Last Update Date | 11/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 312 S CEDROS AVE STE 334
-----------------------------------------------------
City | SOLANA BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92075-1981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-783-5603
-----------------------------------------------------
Fax | 760-683-8382
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 312 S CEDROS AVE STE 334
-----------------------------------------------------
City | SOLANA BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92075-1981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST
-----------------------------------------------------
Name | MISS MICHELLE MARIE YORK
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 760-783-5603
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 91175
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------