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General NPI Number Information
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NPI Number | 1588413538
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Entity Type | Organization
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Legal Business Name | INTEGRATIVE MARRIAGE FAMILY AND INDIVIDUAL THERAPY, INCORPORATED
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Dates
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Enumeration Date | 05/14/2024
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Last Update Date | 10/27/2025
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Provider Practice Location Address
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Address Line | 3431 SLY PARK RD
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City | POLLOCK PINES
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State | CA
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Zip | 95726-9520
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Country | US
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Telephone | 530-206-0335
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Fax |
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Provider Business Mailing Address
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Address Line | 4231 BALBOA AVE # 1509
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City | SAN DIEGO
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State | CA
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Zip | 92117-5504
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Country | US
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Telephone | 530-206-0335
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | LA TISHA LYNN SAN PEDRO-LINTAG
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Credential |
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Telephone | 916-583-4426
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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 |
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License Number State |
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