=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497874770
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLIN DAVID THOMAS LMFT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2007
-----------------------------------------------------
Last Update Date | 08/31/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 714 W OLYMPIC BLVD STE 704
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90015-1439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-712-3411
-----------------------------------------------------
Fax | 213-749-1875
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12440 COOKACRE AVE APT 108
-----------------------------------------------------
City | LYNWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90262-5357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-347-7577
-----------------------------------------------------
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 | 115350
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 115350
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------