=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104698364
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUKAS DZIEMIDOK MS, LMFT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2023
-----------------------------------------------------
Last Update Date | 10/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13126 1/4 VALLEYHEART DR
-----------------------------------------------------
City | STUDIO CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91604-1980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 747-356-8388
-----------------------------------------------------
Fax | 323-381-5958
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12605 VENTURA BLVD # 1078
-----------------------------------------------------
City | STUDIO CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91604-2415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 747-356-8388
-----------------------------------------------------
Fax | 323-381-5958
-----------------------------------------------------
=====================================================
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 | 142282
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------