=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649810664
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDFUL RESTORATION - A MARRIAGE & FAMILY THERAPY PROFESSIONAL CORPORA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2020
-----------------------------------------------------
Last Update Date | 01/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4050 KATELLA AVE STE 213
-----------------------------------------------------
City | LOS ALAMITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90720-3486
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-350-2713
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4050 KATELLA AVE STE 213
-----------------------------------------------------
City | LOS ALAMITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90720-3486
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-350-2713
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | JODEE MAGACALAS-GOSSETT
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 714-350-2713
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------