=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356639348
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A L T WELLNESS GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2011
-----------------------------------------------------
Last Update Date | 07/12/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15720 VENTURA BLVD SUITE 510
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-2914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-730-8007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15720 VENTURA BLVD SUITE 510
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-2914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-730-8007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PARTNER
-----------------------------------------------------
Name | TAMARA E ROBINSON
-----------------------------------------------------
Credential | M.A., MFT
-----------------------------------------------------
Telephone | 818-730-8007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MFC48356
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MFC45037
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------