=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578694410
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOUSHUMI G GHOSE MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2007
-----------------------------------------------------
Last Update Date | 04/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 N BRAND BLVD UNIT 200
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91203-3590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-397-4250
-----------------------------------------------------
Fax | 818-936-0593
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1625 N SUMNER ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97217-3745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-739-4250
-----------------------------------------------------
Fax | 818-936-0593
-----------------------------------------------------
=====================================================
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 | 44134
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC44134
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------