MEDICARE: BLANCA ROSA AYALA BA

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	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1083834527
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLANCA ROSA AYALA BA

Provider Business Mailing Address
First Line	:	16441 WATERWAY CIR APT A
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92649-3252
Country	:	US
Telephone Number	:	714-840-0563
Fax Number	:

Provider Business Practice Location Address
First Line	:	1615 FRENCH ST
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92701-2475
Country	:	US
Telephone Number	:	714-824-8140
Fax Number	:

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

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	07/08/2007

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