=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124348065
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JUDITH GLICKMAN ZEVIN, PSY.D., MARRIAGE AND FAMILY THERAPY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2010
-----------------------------------------------------
Last Update Date | 06/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1151 DOVE ST STE 278
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-2840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-651-6054
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1151 DOVE ST STE 278
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-2840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-651-6054
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | DR. JUDITH GLICKMAN ZEVIN
-----------------------------------------------------
Credential | LCSW, PSY.D.
-----------------------------------------------------
Telephone | 949-651-6054
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCS12553
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------