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General NPI Number Information
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NPI Number | 1558720904
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Entity Type | Organization
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Legal Business Name | PACIFIC MARRIAGE & FAMILY THERAPY NETWORK, A PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 02/14/2016
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Last Update Date | 05/05/2022
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Provider Practice Location Address
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Address Line | 2716 OCEAN PARK BLVD STE 3075
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City | SANTA MONICA
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State | CA
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Zip | 90405-5232
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Country | US
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Telephone | 310-612-2998
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Fax |
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Provider Business Mailing Address
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Address Line | 2716 OCEAN PARK BLVD STE 3075
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City | SANTA MONICA
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State | CA
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Zip | 90405-5232
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Country | US
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Telephone | 310-612-2998
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Fax | 310-943-2590
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Authorized Official
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Title or Position | PRESIDENT
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Name | TRACY KOVACS BEVINGTON
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Credential | MA, MFT
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Telephone | 310-226-2826
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 53455
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License Number State | CA
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