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General NPI Number Information
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NPI Number | 1205650397
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Entity Type | Organization
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Legal Business Name | BLOSSOM FORTH FAMILY COUNSELING INC
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Dates
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Enumeration Date | 11/14/2024
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Last Update Date | 11/14/2024
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Provider Practice Location Address
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Address Line | 710 S MYRTLE AVE # 661
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City | MONROVIA
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State | CA
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Zip | 91016-3423
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Country | US
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Telephone | 626-622-5262
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Fax |
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Provider Business Mailing Address
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Address Line | 710 S MYRTLE AVE # 661
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City | MONROVIA
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State | CA
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Zip | 91016-3423
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Country | US
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Telephone | 626-622-5262
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Fax |
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Authorized Official
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Title or Position | LMFT, CLINICAL DIRECTOR
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Name | BERENICE DURAN-GOMEZ
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Credential | M.A., LMFT 129876
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Telephone | 626-622-5262
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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