=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275301889
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MADLEY & MINK PSYCHOTHERAPY CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2023
-----------------------------------------------------
Last Update Date | 12/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 N MARENGO AVE STE 319
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91101-1982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-739-9016
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 N MARENGO AVE STE 319
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91101-1982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ASHLEY MINK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-739-9016
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------