MEDICARE: RESILIENCY SHOPPE MARRIAGE AND FAMILY THERAPY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker
2	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1073189726
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESILIENCY SHOPPE MARRIAGE AND FAMILY THERAPY INC

Provider Business Mailing Address
First Line	:	14622 VENTURA BLVD
Second Line	:	SUITE 102 PMB 2029
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91403
Country	:	US
Telephone Number	:	818-564-7538
Fax Number	:

Provider Business Practice Location Address
First Line	:	520 S SEPULVEDA BLVD STE 409
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-3547
Country	:	US
Telephone Number	:	818-564-7538
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	KAREN RIVAS
Credential	:
Telephone Number	:	818-923-0717

Provider Enumeration Date	:	06/02/2021
Last Update Date	:	06/02/2021

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