=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114783594
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVAN PERLO MA, LMFT, CGP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2024
-----------------------------------------------------
Last Update Date | 02/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2001 S BARRINGTON AVE STE 215
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90025-5385
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-591-4841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11970 MONTANA AVE APT 106
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90049-5021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-591-4841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 129083
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------