=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265798458
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IVY AUTUMN HECK M.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2012
-----------------------------------------------------
Last Update Date | 03/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1848 S ELENA AVE STE 105
-----------------------------------------------------
City | REDONDO BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90277-5710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-254-4200
-----------------------------------------------------
Fax | 310-540-4580
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1848 S ELENA AVE STE 105
-----------------------------------------------------
City | REDONDO BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90277-5710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-254-4200
-----------------------------------------------------
Fax | 310-540-4580
-----------------------------------------------------
=====================================================
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 | 52515
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------