=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194920983
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSE REY MFT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2081 PALOS VERDES DR N
-----------------------------------------------------
City | LOMITA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90717-3701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-517-4378
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1603 LYMAN PL APT 1
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90027-5438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-517-4378
-----------------------------------------------------
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 | MFC 42487
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------