=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356702146
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTEN ROUAULT LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2016
-----------------------------------------------------
Last Update Date | 09/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25550 HAWTHORNE BLVD STE 316
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90505-6832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-761-9116
-----------------------------------------------------
Fax | 310-945-3356
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25550 HAWTHORNE BLVD STE 316
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90505-6832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-761-9116
-----------------------------------------------------
Fax | 310-945-3356
-----------------------------------------------------
=====================================================
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 | 105222
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------