=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295995959
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MANAL MARY NASRY MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2008
-----------------------------------------------------
Last Update Date | 04/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16350 FILBERT ST
-----------------------------------------------------
City | SYLMAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91342-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-364-2152
-----------------------------------------------------
Fax | 818-362-3446
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16350 FILBERT ST
-----------------------------------------------------
City | SYLMAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91342-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-364-2152
-----------------------------------------------------
Fax | 818-362-3446
-----------------------------------------------------
=====================================================
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 | 116147
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------