MEDICARE: MOIRA REPOLA MFT

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	101YM0800X	Mental Health Counselor	MFT40550	CA

General Provider Information

NPI Number	:	1073713582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOIRA REPOLA MFT

Provider Business Mailing Address
First Line	:	PO BOX 1325
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90267-1325
Country	:	US
Telephone Number	:	310-600-5502
Fax Number	:

Provider Business Practice Location Address
First Line	:	1603 AVIATION BLVD
Second Line	:	SUITE F
City	:	REDONDO BEACH
State	:	CA
Zip	:	90278-2858
Country	:	US
Telephone Number	:	310-600-5502
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2007
Last Update Date	:	07/23/2007

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