=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356357214
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE ANNE SEELY MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2006
-----------------------------------------------------
Last Update Date | 01/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3808 W RIVERSIDE DR SUITE 503
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91505-4325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-863-6560
-----------------------------------------------------
Fax | 818-863-6560
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1825 CERRO GORDO ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90026-2033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-863-6560
-----------------------------------------------------
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 | 41680
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------