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General NPI Number Information
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NPI Number | 1942021589
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Entity Type | Organization
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Legal Business Name | FULL DISCLOSURE THERAPY
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Dates
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Enumeration Date | 10/17/2024
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Last Update Date | 10/17/2024
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Provider Practice Location Address
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Address Line | 172 S ACADEMY AVE STE 150
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City | EAGLE
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State | ID
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Zip | 83616-6564
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Country | US
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Telephone | 208-668-2701
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Fax |
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Provider Business Mailing Address
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Address Line | 238 S NESKOWIN WAY
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City | EAGLE
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State | ID
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Zip | 83616-4964
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Country | US
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Telephone | 310-570-6897
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JULIE M RODIN
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Credential | LMFT
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Telephone | 310-570-6897
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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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