=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992095806
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHIRLEY ROSS LOEB MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2011
-----------------------------------------------------
Last Update Date | 04/12/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1460 7TH ST SUITE 300
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90401-2629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-795-8007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1118 3RD ST UNIT 506
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90403-5087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-744-8281
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | MFC42279
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------