=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164063491
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOBLE'S MARRIAGE AND FAMILY THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2019
-----------------------------------------------------
Last Update Date | 10/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30900 RANCHO VIEJO RD STE 140245
-----------------------------------------------------
City | SAN JUAN CAPISTRANO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92675-1762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-212-6383
-----------------------------------------------------
Fax | 949-216-5674
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30900 RANCHO VIEJO RD STE 140245
-----------------------------------------------------
City | SAN JUAN CAPISTRANO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92675-1762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-212-6383
-----------------------------------------------------
Fax | 949-216-5674
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPY
-----------------------------------------------------
Name | CAROLYN NOBLE
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 949-212-6383
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------